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Full text of "Obstetrics for nurses"

WY 157 R323o 1917 



54511070R 



NLM DS2fi7blb ^ 



NATIONAL LIBRARY OF MEDICINE 



SURGEON^ GENERAL'S OFFICE 

LIBRARY. 



Section 

,v„. i 

No. 113, 

W.D.S.G.O. 



OBSTETRICS FOR NURSES 



OBSTETRICS 

FOR NURSES 



/ 

CHARLES B. REED, M.D., 
** » 

Obstetrician to Wesley Memorial Hospital, Chicago. 



ONE nVNDHKD THIRTY ILLUSTRATIONS 



ST. LOUIS 

C. V. MOSBY COMPANY 

1917 



!BRAR> 



COPYRICIIT, 1917, BY C. V. MOSBY COMPANY 




Press of 
C. V. Mosby Company 
St. Louis 



GCLA478235 



TO HIS LOYAL FRIEND 

EUGENE S. GILMORE 

THIS BOOK IS AFFECTIONATELY DEDICATED 
BY THE AUTHOR 



PREFACE 



It might seem that an apology was necessary for 
presenting a new textbook on obstetrics for nurses 
when so many are to be had for the asking. But when 
a teacher is rarely or never satisfied with his own 
work it is too much to expect that he will ever fully 
endorse the product of another. It may be therefore 
largely a personal matter that none of the exist en1 
books seem to exhibit the fullness of information, the 
conciseness of expression, and the emphasis due to cer- 
tain subjects that the present writer would hope to 
find. 

The necessities apparently demand such an arrange- 
ment of our obstetrical doctrine that the book may 
serve for class instruction and at the same time be 
complete enough for post-graduate reference. 

To secure this much discrimination is necessary. The 
confusion attendant upon overabundance must be 
avoided as well as the discouragement that is not in- 
frequently produced by a large book or a periphrastic 
style. 

Hitherto there has been a tendency to teach the 
nurse too little rather than too much but conditions 
have changed. Vocational instruction is not only more 
methodical and far reaching but it is developmental. 
The present day nurse expects not merely to assist 
the physician and earn a stipulated reward, but she 
is constantly alert to attain her own maturity as a pro- 
fessional woman. 

To be a capable and intelligent assistant it is not 
sufficient to have a clear comprehension of her particu- 

7 



8 



PREFACE 



lar duties, bul she must have a defined and critical con- 
ception of what the doctor is aiming to accomplish. 

This is especially true in obstetrics where the nurse 
has the additional responsibility of giving support and 
counsel to her patient in the various emergencies that 
arise. Moreover, to attain her intellectual maturity the 
nurse must strive unremittingly to understand the 
complicated processes that take place under her obser- 
vation. 

She must cooperate with her doctor whose associate 
she is and secure the confidence of her patient who re- 
lies upon her for guidance in the perils she is facing. 
For childbirth is a peril. It is no longer the normal 
process it once was. Civilization has changed the shape 
of the pelvic bones, altered the muscles of parturition 
and weakened the nerve centers that control the event. 

The birth of a child is equal in severity and serious- 
ness to many of the major operations. It is not an 
affair to be entered upon lightly nor managed without 
the utmost foresight and care. 

The dangers that are recognized and prepared for 
in this book by what may seem to some to be an ex- 
travagant technic, are very real dangers, extremely 
subtle, and against them at times every precaution and 
every defense proves unavailing. 

Nevertheless, skill, thoughtfulness, and above all, 
cleanliness, will avert the worst, as well as unhappily 
the most common of these disasters. If our nurses 
could be convinced of this, the difficulties and appre- 
hensions of childbirth would be greatly diminished. 

The nurse should see to it that her patient is sur- 
rounded by all the precautions and safeguards against 
infection that she would demand for a member of her 
oavii family. This means of course that her work will 



PREFACE 



9 



be far more exacting and onerous but also it Avill save 
many nights of anxiety and not infrequently a life. 

This book represents the obstetric ideas and technic 
which the writer has endeavored for years to impress 
upon his students and nurses with such emendations 
and changes as experience and scientific progress have 
suggested. It is a selective essence distilled from the 
recurrent harvests that workers in this field have 
brought forth during centuries of consecrated effort. 
To all these forerunners the writer acknowledges a 
deep personal indebtedness. 

In the preparation of the book thanks are due par- 
ticularly to Charlotte Gregory, Head Nurse of the 
Wesley Maternity, whose rare ability as teacher, tech- 
nician and executive and whose untiring vigilance has 
been a leading factor in securing and maintaining the 
high state of efficiency in this department. She lias 
kindly contributed Chapters XXIII and XXIV, to- 
gether with valuable suggestions and criticisms in other 
portions of the text. 

The author also takes pleasure in acknowledging his 
obligations to Florence Olmstcad, Head Nurse of the 
Dispensary of the Northwestern University Medical 
School, whose long experience in feeding babies gives 
to her Avords an unquestioned authority. Chapter XXII 
is almost entirely her work. 

To the various publishers who have courteously al- 
lowed the reproduction of valuable illustrations from 
the books of other writers thanks are also extended, 
and to his own publishers especially for their cordial 
and sympathetic cooperation the author wishes to ex- 
press his warmest gratitude. 

C. B. R. 

Chicago, 1917. 



CONTENTS 



Anatomy 

CHAPTER II 



CHAPTER I pag 13 

.... 17 



33 



Physiology 

CHAPTER III 

Normal Pregnancy 51 

CHAPTER IV 

Hygiene of Normal Pregnancy 66 

CHAPTER V 

Abnormal Pregnancy 74 

CHAPTER VI 

Abnormal Pregnancy (Continued) 89 

CHAPTER VII 

Preparations for Labor and the Normal Course of Labor 98 

CHAPTER VIII 
The Mechanism of Normal Labor 120 

CHAPTER IX 

The Care of the Patient During Normal Labor .... 129 
CHAPTER X 

151 

The Normal Puerperium 

CHAPTER XI 

Unusual Presentations and Positions 16a 

CHAPTER XII 

179 

Operations 

11 



12 CONTENTS 

CHAPTER XIII PAGE 

Minor Operations 200 

CHAPTER XIV 

Complications in Labor 214 

CHAPTER XV 

Complications in Labor (Continued) 228 

CHAPTER XVI 

The Abnormal Puerperium 242 

CHAPTER XVII 
Infection 255 

CHAPTER XVIII 
The Care of the Child 265 

CHAPTER XIX 

The Care of the Child (Continued) 278 

CHAPTER XX 

The Care of the Child (Continued) 287 

CHAPTER XXI 
The Care of the Child (Continued) 298 

CHAPTER XXII 
Infant Feeding 310 

CHAPTER XXIII 
Cleanliness and Sterilization 323 

CHAPTER XXIV 
Diets and Formulae 330 

CHAPTER XXV 
Solutions and Therapeutic Index 340 



ILLUSTRATIONS 

FIG. PAGE 

1. The normal female pelvis 18 

2. The planes of the brim, the cavity, and the outlet ... 19 

3. Visceral relations 20 

4. Uterus and appendages 22 

5. Normal position of pelvic organs 24 

6. The external genitals 25 

7 A. Varieties of hymen 27 

7B. Varieties of hymen 28 

8A. The excreting ducts of the mammary gland 29 

SB. Lobules and duct of the mammary gland 29 

9. Nipple, areola, and the glands of Montgomery .... 30 

10. Supernumerary milk glands in the axilhe 31 

11. The three ages of the breast 31 

12. Development of the ovary 34 

13. Graafian follicles 35 

14. Human spermatozoa 36 

15. The chorionic villi about the third week of pregnancy . 38 
1(5. Diagram illustrating relations of structures of the human 

uterus at the end of the seventh week of pregnancy 39 

17. Maternal surface of the placenta and membranes ... 40 

IS. Fcetal surface of human placenta 41 

19. The egg at term with uterus removed 42 

20. Normal attitude of foetus 43 

21. Fcetal skulls showing sutures 44 

22A and B. Child's head at term, showing diameters ... 45 

23. The foetal circulation 49 

24. Gravid uterus at the end of the eighth week 52 

25. Striae gravidarum 54 

26. Bimanual examination . 60 

27. Abdominal enlargement at different months of pregnancy 63 

28. Height of the uterus at various months of pregnancy . . 64 

29. Twins 83 

30. Diagram representing the sites for the various forms of 

tubal pregnancy 90 

31. Abdominal binder with crosspiece to hold vulvar pads . 100 

13 



14 



ILLUSTRATIONS 



FIG. PAGE 

32. T-binder, used in all cases after the fifth day post partum 100 

33. Breast binder 101 

34. Baby's dress with winged sleeves 102 

35. The lias of waters begins to act on the cervix . . . . Ill 

36. The effect of the pains. The cervix before labor begins 112 

37. The effect of the pains. The cervix begins to be ''effaced" 112 
3S. The effect of tiie pains. The cervix is effaced, and the 

dilatation of the os begins 113 

39. The effect of the pains. The cervix is effaced, and. the os 

continues to dilate 113 

40. The cervix is effaced and the os dilated 115 

41. Child in second stage of labor 116 

42. The head passing over the perineum 117 

43. Normal expulsion of the placenta according to Schultze . 118 

44. The child in left-occipito-anterior position 122 

45. The child in right-occipito-anterior position 123 

46. The descent of the head in right-occipito-anterior position 124 

47. Internal anterior rotation and extension of the head in a 

lcft-occipito-antcrior position 124 

48. Extension 125 

49. Extension completed. Expulsion 125 

50. A cephalhematoma 127 

51. Points of greatest intensity of foetal heart tones . . . 130 

52. Handling forceps, kept sterile in a jar of alcohol . . . 132 

53. Palpation. What is in the pelvis? 134 

54. Palpation. What is in the fundus? 135 

55. Palpation. Where is the back? Where are the small parts? 136 

56. Patient draped for internal examination 137 

57. Delivery in side position 141 

58. Sheet twisted into a sling 147 

59. Repair of perineum 148 

60. The progress of involution 152 

61. The breech. Left-sacro-anterior position 166 

62. The breech. Left-sacro-posterior position 167 

63. Extraction of the breech 170 

64. Breech delivery. Extraction of the trunk 171 

65. Breech delivery. Delivering the shoulder 172 

66. The delivery of the after coming head by the Smellie- 

Veit maneuver 172 

67. Shoulder presentation I70 



ILLUSTRATIONS 15 

FIG - PAGE 

68. Face presentation 175 

69. Descent of the chin in face presentation 176 

70. Delivery in face presentation 177 

71. Exaggerated lithotomy position 181 

72. Dorsal position when assistants are available 1S2 

73. Instruments for artificial delivery of the head .... 183 

74. Forceps operation. Introduction of the left blade . . . 186 

75. Forceps operation. The introduction of the right blade . 187 

76. Forceps operation. Locking the handles 187 

77. Forceps operation. The way the blades should grasp the 

foetal head 188 

78. Forceps operation. Traction on the handles 189 

79. Forceps operation. The delivery of the head 189 

80. Version. Seizing a foot 190 

81. Version. The child rotates as pressure is made upon the 

head and traction upon the foot 191 

82. Version is complete when the knee appears at the vulva . 192 

83. The Walcher position 19-4 

84. The Wiegand compression of the child's head to force it 

into the pelvis 195 

85. The Naegele perforator 196 

86. Apparatus for getting a sterile specimen of urine from 

an infant 201 

87. Tampon of the uterus 203 

88. Tampon of vagina 20.4 

89. Pean forceps 208 

90. Hand bulb syringe; and Vorhees bags; bag rolled and 

grasped by Pean forceps ready for introduction . . 209 

91. Vorhees bag in place 210 

92. Episiotomy 212 

93. Various forms of pelvic deformity 215 

94. The pelvimeter 216 

95. The various diameters of the inlet 216 

96. Measuring the distance between I he anterior superior 

97. Measuring the external conjugate 21S 

98. Measuring the diagonal conjugate with the finger . . . 219 

99. Various forms of placenta prsevia 229 

100. The knee-elbow posture 236 

101. The knee-chest posture 236 



16 



ILLUSTRATIONS 



FIG. rAGE 

102. The exaggerated lithotomy position obtained with a sheet 

sling 237 

103. The improvised Trendelenburg position 237 

104. The dorsal position with stirrups 238 

105. Doi sal position across the bed 239 

106. Flexed dorsal position with feet on the table 240 

107. The Sims position 241 

108. Examples of imperfect nipples 245 

109. A standard nipple shield 24G 

110. A standard breast pump 251 

111. Germs most frequently found in cases of puerperal fever 256 

112. Rubber bath tub 266 

113. The Pettit cord clamp 268 

114. Standard breast pump; Standard nursing bottle; the 

breast tray ; the Wansbrough lead nipple shield ; the 

Brophy nipple for harelip and cleft palate . . . 271 

115. Proper position of mother while nursing child .... 274 

116. Proper method of taking rectal temperature . . . . 276 

117. Method of passing the tracheal catheter 279 

118. Byrd's method of artificial respiration. Extension and 

inspiration 280 

119. Byrd's method of artificial respiration. Beginning flexion 

and expiration 280 

120. Byrd's method of artificial respiration. Flexion and 

compression 281 

121. Method of giving gavage 284 

122. Apparatus for gavage or lavage 286 

123. Cleft palate nipple 288 

124. The device for feeding the child with cleft palate . . . 288 

125. Device for assisting the cleft palate child to nurse . . 289 

126. Method of strapping an unbilical hernia 290 

127. Proper position for introduction of a suppository . . . 299 

128. Hydrocephalus 307 

129. Aneneephalus 308 

130. Elements of human milk 312 



OBSTETRICS FOR NURSES 



CHAPTER I 
ANATOMY 

The study of obstetrics is an investigation of the 
passage, the passenger, and the driving powers of labor, 
as well as of the various complications and anomalies 
that may attend the process of reproduction. 

The passage is composed of a bony canal, called the 
pelvis, and the soft tissues which line and almost close 
its outlet. 

The pelvis is made up of four bones; the sacrum, the 
coccyx, and two other large structures of irregular 
shape, called the hip, or innominate bones. Joined by 
cartilage and held in place by ligaments, they form a 
cavity or basin which, in the male is deep, narrow, 
small and funnel-shaped, while in the female, slighter 
bones, expanded openings and wider arches make a 
broad, shallow channel, through which the child is born. 

The bony pelvis is divided for description into two 
parts, the upper or false pelvis, and the lower or true 
pelvis. The upper pelvis is formed by the wings of 
the innominate bones and has but two functions of im- 
portance to child-bearing. It acts as a guide to direct 
the child into the true passage, and when measured by 
the pelvimeter, it gives information as to the shape 
and size of the inlet to the true pelvis. The true pelvis 
is of most concern to the obstetrician, because anomalies 
in its size or shape may impede the progress of labor or 

17 



IS 



OBSTETRICS FOR NURSES 



retider it impossible. The pelvis is divided conveniently 
into three parts: the brim, the outlet, and the cavity. 

The brim, inlet, or upper pelvic strait, is the boundary 
line between the false and true pelvis. It is traced from 
the upper border of the symphysis along the iliopectineal 
line on both sides to the promontory of the sacrum. 
The shape and size of this opening varies much in dif- 
ferent races and individuals, both normally and through 




Fig. 1. — The normal female pelvis. (Eden.) The lines ab and cd divide 
the pelvis into the right and left anterior and the right and left posterior 
quadrants, ab indicates the anteroposterior diameter of the brim, cd shows 
the transverse diameter while fh and cf represent, respectively, the right 
and left oblique diameters. 



disease; and when pathologically altered, both shape 
and size may exercise a marked influence on the course 
of labor. In American women, the outline of the brim 
is roughly heart-shaped, like an ovoid with an indenta- 
tion where the promontory of the sacrum impinges upon 
the opening. 



ANATOMY 



19 



The brim or inlet has four important diameters to be 
remembered ; important because the hard, round head 
of the child must pass through them by accommodating 
its diameters as favorably as possible to those of this 
opening. These diameters are named respectively the 
anteroposterior or conjugate diameter, the transverse, 
and the right and left oblique diameters. The two 
oblique diameters attain their greatest importance when 
the pelvis is irregularly distorted, but the others are 
essential in every case where labor impends. It is to 
secure an estimate of these latter diameters that the 



c 




Fig. 2. — The nlancs of (a) the brim, (6) the cavity and (c) the outlet. 
(Eden.) 



bony prominences are measured. This upper opening 
lies not horizontally, but in oblique relation to the body 
in standing position, and the weight of the abdominal 
viscera rests largely upon the bones and in consequence 
does not crowd into the inlet unless forced in by corsets 
or faulty habits. 

Passing through the brim, a cavity is found below it, 
midway between the inlet and outlet, which is nearly 
round in shape. This is the "excavation," or the true 
pelvis. Then comes the outlet, bounded in front by the 
pubic arch and soft parts, and behind by the coccyx 
pushed back as far as it can go. It is ovoid in shape, 
but the long axis of this ovoid lies at right angles with 
the axis of the ovoid inlet. 



20 



OBSTETRICS FOR NURSES 



We find, therefore, a succession of three geometric 
figures or planes through which the head must pass by 
means of a spiral motion called rotation. These figures 
are inclined to one another so markedly in front that 
a line drawn through the center of each will curve 
forward at both ends, one end passing out near the urn- 




Fig. 3. — Visceral relations. (Redrawn from Gray.) 



bilicus, the other through the vulva. This is known as 
the axis of the pelvis or the curve of Cams. 

THE SOFT PARTS 

Inside the pelvis are the organs of generation with 
their accessory structures and supporting tissues. 



ANATOMY 



21 



Of first importance are the ovaries, tubes and uterus, 
together with the vagina. These special structures are 
the true genital organs. They are bounded in front by 
1he bladder, behind by the rectum, above by the ab- 
dominal viscera, and surrounded everywhere by muscu- 
lar, mucous and fatty tissues, which support them and 
aid their function. 

The Vagina. — The vagina is a hollow organ, about 
four inches long, attached to the cervix above and the 
vulva below. It is an elastic sheath bounded in front 
by the bladder and behind by the rectum. Under nor- 
mal conditions, this tube easily admits one or two fin- 
gers, but during labor it dilates enormously to allow the 
head to pass. The vagina is lined with a thick mucous 
membrane, ridged and roughened by folds, which are 
called rugae. Thus a continuous channel connects the 
ovary with the outside and through it pass, at appropri- 
ate times, the ovule, the menstrual blood, the uterine 
secretions, the child, the placenta, and the lochia. 

The Uterus. — The uterus (womb) is a pear-shaped 
organ, flattened from before backward, and composed of 
unstriped or involuntary muscle cells and connective 
tissue. Normally the virgin uterus measures from two 
and one-half to three inches in length, and weighs about 
two ounces. It is suspended in the middle of the pelvis 
by strong ligaments, so that the fundus inclines gently 
forward against the bladder. "When the bladder fills, 
the uterus is pushed backward. Most of the organ is 
internal, but a small part of the lower pole is grasped 
by the vagina, in which the lower end with its invalu- 
able aperture, the os, dips and swings. The part above 
the vagina is called the body or fundus, and is covered 
with the serous membrane (peritoneum) that lines the 
abdominal cavity. Below the fundus is the cervix or 
neck, which lies partly above and partly within the 



22 



OBSTETRICS FOR NURSES 



vagina. The cavity of the uterus is usually closed by 
the apposition of the walls. The inner surface is covered 
with a peculiar kind of membrane called the endo- 
metrium, which is highly vascular. The uterine cavity 
opens into the vagina through the os, which is small 
and round in the nulliparous woman, and slit-shaped or 
gaping in the woman who has borne a child. 

Fallopian Tubes. — On either side of the upper end of 




Fig. 4.— Uterus and appendages. On either side of the uterus will be 
seen the ovary, the fimbriated extremity of the tube, the tube, and the 
round ligament. The vagina lies open below. (Eenoir and Tarnier ) 



the uterus are the orifices of the Fallopian tubes, through 
which the egg, escaping from the ovary, finds access to 
the uterine cavity. These tubes extend outward from 
the uterus about four inches, and terminate in a bell- 
shaped opening with long, ragged fingers which hang 
loosely down toward the ovary. The tubes are lined by 
epithelial cells having hair-like projections, (cilise) 
which wave automatically toward the uterus. Thus im- 



ANATOMY 



23 



pellecl by a gentle current, the egg moves definitely 
along the tube toward the uterus and against this cur- 
rent the spermatozoa force their way to meet and fertilize 
the egg. 

The Ovaries. — On either side of the pelvis, close to 
the fringed end of the Fallopian tube and attached to 
it, lies a small, hard, almond-shaped organ, called the 
ovary. This is the intrinsic sexual gland of the female. 
It contains the small cells which are to ripen and be- 
come eggs. Each ovary is said to contain about thirty- 
six thousand eggs, or ovules. 

The Bladder. — The bladder lies between the pubic 
bone and the uterus. It is a reservoir for urine, filled 
by means of two little tubes called ureters, that run 
down from the kidneys. It drains through the urethra 
which opens just below the pubic bone in front of, and 
just above, the vaginal opening. The bladder should be 
emptied frequently during labor. 

The Anus. — The large bowel (colon) terminates in an 
opening near the middle of the genital crease. This 
opening is called the anus. It is closed by a contract- 
ing muscle, the sphincter, which acts like a puckering 
string. Just inside of the opening is a group of large 
veins which may become enlarged, inflamed, and bleed 
during pregnancy. They are then called hemorrhoids. 

The Rectum. — Upward from the anus and to the left 
of the uterus extends the rectum. This is the end of the 
intestinal canal and is supplied with an abundance of 
nerves. When the head presses upon it, it gives the 
serlsation of a bowel movement, and warns the observer 
of the low position of the head. The anus pouts as the 
head comes down and the anterior walls become vis- 
ible. In severe cases of labor, the sphincter is some- 
times torn. The bowels should be emptied by an enema 
as early as possible in the first stage of labor. 



•24 



OBSTETRICS FOR NURSES 



The Peritoneum.— Th e peritoneum is a thin, glisten- 
ing, serous membrane, which lines the abdominal cavity 
and drops down from above over the uprising tops of 
the bladder and uterus. Folding together at the sides 
and extending to the walls of the pelvis, it encloses the 
tubes and round ligaments in deep, flat masses, called 
the broad ligaments. This is the structure that becomes 
so perilously inflamed (peritonitis) when infected by 
germs that find entrance through the genital passage. 




Fig. 5. — Normal position of pelvic organs, seen from above and in front. 
They are enveloped in peritoneum. (Bougery and Jacob, in American 
Text Book.) 

THE EXTERNAL GENITALS 

The external genitals form the vulva. Under this 
name are included the mons veneris, the labia majora, 
the labia minora, the clitoris, the vestibule, the hymen 
and the glands of Bartholin. 



ANATOMY 



25 



The entire groove from the mons veneris to a point 
well up on the sacrum forms a deep fold or crevice, 
which is known as the genital crease. That part of the 
genital crease lying between the aims and vulva is tech- 
nically known as the perineum (q.v.). 




Introitus 

or 
Orifice 
of Vadino. 



C litoris 

Prepuce 
Glons clit 



Meatus 
or 

Orifice 

of Urethra 

Hymen 

Fourchette 
Fosso 

navicularis 
Perineum 



Anus 




Fig. 6. — The external genitals. (Redrawn from Gray.) 



The Mons Veneris. — The mons veneris is a gently 
rounded pad of fat lying just above the junction of the 
pubic bones (the symphysis). The overlying integu- 
ment is filled with sebaceous glands and covered with 
hair at puberty. 

The Labia Majora.— The labia majora are the large 



26 



OBSTETRICS FOR NURSES 



lips of the vulva. They are loose, double folds of skin 
extending downward from the mons veneris to the an- 
terior boundary of the perineum and covered exter- 
nally with hair. Normally they lie in apposition and 
conceal the vaginal opening. They correspond to the 
male scrotum. 

The Labia Minora. — The labia minora, or nympha?, 
are two small folds of skin and mucous membrane, that 
extend from the clitoris obliquely downward and out- 
ward for an inch and a half on each side of the entrance 
to the vagina. On the upper side, where they meet and 
invest the clitoris, the fold is called the prepuce, but 
on the under side they constitute the frsenum. 

The labia minora are sometimes enormously enlarged 
in the black races and are then called the Hottentot 
apron. 

The Clitoris. — The clitoris is an erectile structure an- 
alogous to the erectile tissue of the penis. The free 
extremity is a small, rounded, extremely sensitive tuber- 
cle, called the glans of the clitoris. About the clitoris 
there forms a whitish substance called smegma. This 
is a good culture medium for germs and must be care- 
fully sponged away when the vulva is prepared for de- 
livery. 

The Vestibule. — The vestibule is bounded by the cli- 
toris above, the labia minora on the sides, and the 
vaginal orifice below. It contains the opening of the 
urethra, which is called the meatus urinarius. 

The Hymen. — The hymen is a thin fold of membrane 
which closes the vaginal opening to a greater or less 
extent in virgins. It varies much in shape and con- 
sistency. It is sometimes absent, or it may persist after 
copulation, hence its presence or absence can not be 
considered a test of virginity. When torn, the edges 



ANATOMY 



27 



shrink up and form little irregularities called carun- 
culas myrtiformes. 

Bartholin Glands. — Bartholin glands are located on 




Fig. 7 A. — Varieties of hymen. (American Text Book.) 



each side of the commencement of the vagina. Each 
gland discharges by a small duct just external to the 
hymen. They are often the seat of a chronic gonorrhceal 



28 



OHSTKTKMCS ['OK NTKSKS 



inflammation and must be watched carefully, lest in l ec- 
tion extend to the mother after labor, or to the eyes of 
the child in passing. 




Fig. 7 B. — Varieties of hymen. (American Text Book.) 



The Perineum.— The perineum is a body of muscle, 
fascia, connective tissue, and skin, situated between 
the vagina and the rectum. The vagina bends forward 



ANATOMY 



29 




Fig. % A. — The excreting ducts of the mammary gland. 
(Lenoir and Tarnier.) 




Fig. 8 B. — Lobules and duct of the mammary gland. (Lenoir and Tarnier.) 

and the rectum backward, so a triangular area is left 
between them which is filled by the perineal body. It 
is about two inches long from before backward, and be- 
comes progressively thinner the deeper it extends. 
The perineal body is flattened out and compressed 



30 



OBSTETRICS FOR NURSES 



by the passage of the head and in many cases torn. 
(Thirty per cent of primiparas and ten to fifteen per 
cent of multiparas.) It should be repaired immediately. 

The Mammary Glands. — The mammary glands are 
secondary but highly important parts of the genital sys- 
tem. They are formed by a dipping down of skin glands 
and they perform the special function of secreting milk. 

The breast is made up of fifteen or twenty lobes, each 
of which, like a bunch of grapes, clusters about and 




Fig. 9. — Nipple, areola, and the glands of Montgomery. (Eden.) 

discharges into a single tube which, in turn, leads to 
the nipple. The area between the lobes is filled with 
fat and connective tissue. 

The nipple is pink or darkly pigmented. It is com- 
posed of erectile tissue and under stimulation, it rises 
from the surface of the gland so that it is easily taken 
into the mouth. 



ANATOMY 



:31 



Surrounding the nipple is a darkly pigmented area 
from one inch to four inches in diameter that is called 
the areola. It contains hard, shot-like nodules, the 
glands, or tubercles, of Montgomery. These often secrete 




Fig. 11.— The th ree ages of the breast — virginity, maturity, and senescence. 
(Witkowski.) 



milk and sometimes become infected. It occasionally hap- 
pens that more than two breasts may be found on the 
human female, and not infrequently pieces of mammary 



32 



OBSTETRICS FOR NURSES 



tissue may be discovered in the axilla or on the chest or 
back. 

The mammary gland is undeveloped at birth, but, nev- 
ertheless it may fill with milk (witches' milk). At pu- 
berty, after marriage, and during pregnancy, the gland 
reaches maturity. It is only after delivery, however, 
that the functional climax is attained. 



CHAPTER II 



PHYSIOLOGY 

Ovulation. — Ovulation is the process whereby the eggs 
are discharged from the Graafian follicle which matures 
and protects them in the ovary. The egg is a true cell 
with one, and sometimes more than one, nucleus. 

The ripening of the eggs, as well as their discharge, 
is attended with much general disturbance and great 
physical changes. This phenomenon begins from the 
twelfth to the fifteenth year, depending on race, climate, 
occupation and temperament, and marks the transition 
of the individual from childhood into maturity. 

This period is called puberty. At this time the breasts 
enlarge, the hips round out, the vagina, uterus and ex- 
ternal genitals increase in size. Hair appears upon the 
vulva, the emotions become more evident, and modesty de- 
velops through a consciousness of sexual difference and 
attraction. 

Simultaneously a new function appears — 
Menstruation. — Menstruation may be defined as a 
process wherein a bloody fluid is discharged from the 
uterus at regularly recurring periods between puberty 
and the menopause, except during pregnancy and lac- 
tation. It is a haemorrhage which in some way is 
closely associated with ovulation, but it is not known 
positively which is the precedent of the other, 
or whether one causes the other. 

Menstruation is not essential to pregnancy, for preg- 
nancy may occur when the flow is normally absent, as be- 
fore puberty, after the menopause, or during lactation. 

33 



34 



OBSTETRICS FOR NURSES 



Nevertheless, regularity of menstruation is the rule in fer- 
tile women and clinicians agree that while conception may 
occur at any part of the menstrual cycle, it is most likely 
to happen just before or just after the menstrual flow. 

The best authorities at present support the theory 
that ovulation usually occurs soon after the close of 




Fig. 12. — Development of the ovary (after Wiedersheim) . A, an in- 
growth of the germinal epithelium, forming a cell-cord, which breaks up 
into primitive Graafian follicles; B, a primitive Graafian follicle, with its 
contained primitive ovum; C, D, B, later stages in the development of the 
Graafian follicle. (Crossen.) 



the menstrual period. This is confirmed by the similarity 
of the physical changes that take place in the endo- 
metrium during menstruation and after conception. 

As the period of the flow approaches, the lining mem- 
brane of the uterus becomes hypersemic and swollen 



PHYSIOLOGY 



35 



with blood, serum, and glandular secretions. The blood 
vessels are engorged, the glands become longer and 
more tortuous, little hemorrhages appear, and the su- 
perficial epithelium is thrown off. A large amount of 
mucus is produced by the increased activity of the 
glands, and all is discharged into the vagina as a 
bloody, incoagulable flow with an odor of marigolds. 
The process continues usually from three to seven days, 
when the discharge ceases and the endometrium slowly 
resumes its uncongested state. 




mm 



Fig. 13. — Graafian follicles. One contains two ovules which, if fertilized, 
will produce twins. If all three ovules are fertilized, triplets will result 
( Bumm.) 

Meanwhile, the psychic and bodily conditions have 
not remained unaffected. The nervous system is dis- 
turbed, the disposition is irritable and capricious and the 
head may ache. The woman takes cold easily. She is 
indisposed to exertion from a sense of languor and 
malaise. Pain may develop in the back, or cramps in 
the pelvis, so severe as to keep the woman in bed. Fre- 
quently the approach of the period is signalized by skin 
changes, such as a marked odor or an eruption of acne 
pustules. 



36 



OBSTETRICS FOR NURSES 



The flow usually returns every twenty-eight days, but 
it may vary within normal limits from twenty-one to 
thirty days. The flow continues at such intervals regu- 
larly from puberty to the menopause (change of life), 
which occurs between the ages of forty-five and fifty. 

Conception, or Fertilization. — This is the process 
wherein the male element (spermatozoon) meets and 
unites with the female egg. From what is known from 
investigations of lower animals, this meeting usu- 
ally takes place in the Fallopian tube. 




Fig. 14. — Human spermatozoa, h, head; c, intermediate portion; t, tail. 
(Williams.) 

The egg expelled from the ovary is carried into the 
open end of the tube by peritoneal currents and passed 
on toward the uterus by the waving action of the hair-like 
outgrowths of the cells (ciliae) that line the tube, aided, 
possibly, by the tubal muscle. 

The spermatozoon makes its way upward from the 
vagina by means of its tail. This activity, like the tail 
of a fish, or snake, or as a boat is sculled, drives the cell 



PHYSIOLOGY 



37 



f or ward through the thin layer of fluid that covers the 
mucous membranes. 

The arrow-shaped spermatozoon travels at a rate that 
completes the passage to the ovary in twenty-four hours, 
but spermatozoa may lie in wait for the egg a con- 
siderable time, as is shown by the fact that they have 
been found alive in Fallopian tubes removed three and 
a half weeks after copulation. As soon as the male and 
female elements approach each other, they exercise a 
powerful magnetic attraction, which draws them to- 
gether, and as soon as they touch, the two cells unite 
and the spermatozoon almost immediately disappears. 

Only one spermatozoon is required for the fertiliza- 
tion of an egg, and hence enormous numbers must per- 
ish without achieving their destiny. 

The fertilized egg has become the ovum, and origi- 
nally 1/125 of an inch in diameter, it now begins to grow, 
and filled with a new energy, it passes down the tube 
and enters the uterus. Here it comes into contact with 
the soft mucosa and digs a hole for itself — a nest, very 
much as a warm bullet might sink into ice or snow — and 
is soon completely surrounded by a proliferating tissue 
called the decidua. The woman is now pregnant. The 
menstrual floAv does not appear, and local and system- 
atic changes are inaugurated. 

The egg enlarges rapidly. Little glove-finger-like pro- 
jections (the villi) appear on its surface and dip 
down into the maternal tissues. Through these villi 
the egg gets nourishment until about the twelfth w r eek, 
when the placenta forms. Externally the ovum resem- 
bles a chestnut burr. As the egg grows, the villi on 
the surface find it more and more difficult to secure 
nutriment, and except at one place, all gradually shrink 
and disappear. At this significant point, they increase 



38 



OBSTETRICS FOR NURSES 



greatly in size, number, and complexity to form the 
thick, cake-like placenta. 

The egg or ovum is simply a growing cyst, filled with 
a fluid, normally sterile, in which the developing em- 
byro lives and swims. This fluid is the liquor amnii and 
it is retained by a cystic wall made up of two layers— 




Fig. 15. — The chorionic villi about the third week of pregnancy. (Edgar.) 

the chorion, which represents the original cell membrane, 
and the amnion, which develops out of the foetus. At 
maturity, the ovum will contain from one to two pints 
of liquor amnii. 

The Liquor Amnii. — The liquor amnii is of vast im- 
portance to the child. It allows free movement for the 
growing limbs and body, protects the child from sud- 
den changes of temperature, prevents injury both from 



PHYSIOLOGY 



39 



without and within, saves the child from birthmarks 
and deformities by keeping it from contact with the 
surrounding Avails, and in labor lubricates the passages 
for the advancing part. In a measure, too, it probably 




Fig. 16. — Diagram illustrating relations of structures of the human uterus at 
the end of the seventh week of pregnancy. (American Text Book.) 



serves as a food. In labor it forms a pouch called the 
bag of waters, which aids in dilating the os. 

Gradually, as nutrition becomes more abundant at the 
site of the growing placenta, a stalk-like structure 
thrusts out from the foetal abdomen and forms an at- 



40 



OBSTETRICS FOR NURSES 



tachment with the formative placenta, This is called 
the ventral stalk and as soon as the communication 
with the placenta is established, it is combined with 
other parallel structures and becomes vascularized, to 
form the umbilical cord. 




Fig. 17. — Maternal surface of the placenta and membranes. The cord pro- 
trudes from the cavity which held the foetus. (Edgar.) 



The Umbilical Cord. — The umbilical cord at maturity 
measures from five to fifty inches in length and from 
one-half to one inch in thickness. The cord is composed 
of a gelatinous connective tissue, called Wharton's 
jelly, in the midst of which lie the twisted vessels (two 



PHYSIOLOGY 



41 



arteries and a vein) that supply the embryo Avith air 
and food and carry off the waste. 

The Placenta.— The placenta or "after-birth" is an 




Fig. 18. — Foetal surface of human placenta. (Eden.) 



oval or circular somewhat flattened disc, six to ten inches 
in diameter, and three-quarters to one and one-half inches 
thick. It weighs about a pound and a half. It is the organ 
of respiration and nutrition for the foetus. 



42 OBSTETRICS FOR NURSES 

It is formed about the third month outside the mem- 
branes covering the child and is more or less loosely at- 
tached to the uterine wall. The umbilical cord is at- 
tached to its foetal surface, inside the ovum. Like a flat 





Fig. 19. — The egg at term with uterus removed and child showing through 
the membranes. (Edgar.) 

sponge it takes oxygen, blood, and the nourishing fluids 
from the blood vessels in the uterine wall, carries them to 
the child by means of the umbilical vein, and carries back 



PHYSIOLOGY 



43 




Fig. 20. — Normal attitude of foetus (complete flexion). (Barbour.) 

the carbonized blood and waste products by the umbil- 
ical arteries to the placenta, and there returns them to 
the maternal blood for disposal. The blood of the veins 
is bright red, and of the arteries, dark and turbid. 

There is no direct communication between the ma- 
ternal tissues and the placenta, hence all the changes 
occur by osmosis, and by the activity of the cells which 
form the walls of the villi. 



44 



OBSTETRICS FOR NURSES 



The liver of the child is large and active. The stom- 
ach and intestines functionate mildly. The kidneys 
act, and urine is discharged into the liquor amnii, 
which the child occasionally swallows. 

During development, the movements of the child be- 
come more and more pronounced. Arms, legs, and en- 
tire body participate in turn. Periods of rest are also 
observed. Gradually the child assumes a definite at- 
titude in the uterus. It becomes more and more folded 
and flexed to accommodate its size to the limitations of 



b 




Fig. 21. — Foetal skulls showing sutures. Note the differences between the 
anterior and posterior fontanelles. (Eden.) 



space. The head bends on the chest, the arms are 
folded, the thighs flex against the abdomen, the legs 
on the thighs, and even the back ultimately becomes 
convex. It attains a complete flexion, the normal atti- 
tude of the child. As maturity approaches, the head 
becomes more and more palpable and seeks its usual lo- 
cation in the lower pole of the uterus, resting on the 
pelvic brim. 

The fcetal skull at maturity (at term) is still incom- 




Fig. 22 B. — The 



child's head at term (from above), showing diameters and 
fontanellcs. (American Text Book.) 



46 



OBSTETRICS FOR NURSES 



pletely ossified. The bones are thin and pliable and 
separated at their edges by intervals of unossified mem- 
brane which form the sutures and fontanelles. Thus 
the skull is compressible to a slight degree and capable 
of much change in shape. It can be measurably moulded 
by the uterine contractions to suit the pelvis. 

In front, the two coronary sutures meet the frontal 
snd sagittal sutures to produce a kite-shaped figure, 
called the large or anterior fontanelle, or the bregma. 
Behind, the lambdoidal suture meets the sagittal suture 
to form the small or posterior fontanelle. 

The large fontanelle is made up of four bones and 
four angles ; the small, of three bones and three angles, 
and are usually easy to differentiate. Furthermore, 
the difference between these fontanelles is of great im- 
portance in labor, since by it the observer is enabled to 
determine the position of the head. In America, the 
shape of the head is that of an ovoid with the long 
diameter anteroposterior (Dolico-cephalic). Thus it 
happens that when the head is completely flexed, the 
smallest diameters are presented for delivery. 

The important diameters of the head, with their meas- 
urements and names, are as follows: 

Nape of neck to center of bregma, 9.5 cm. — Suboccip- 
ito-bregmatic diameter. Occipital protuberance to root 
of nose, 11.25 cm. — Occipito-frontal diameter. Between 
the eminences of parietal bones, 9.25 cm. — Biparietal 
diameter. Between anterior ends of coronal sutures, 8 
cm. — Bitemporal diameter. 

The smallest circumference is that of the suboccip- 
ito-bregmatic plane, which comes into relation with 
the brim of the pelvis when the flexion of the head is 
complete. It measures 27.5 centimeters. 

The foetus grows at a definite rate throughout gesta- 



PHYSIOLOGY 



47 



tion and so regularly that the increase is rarely simu- 
lated by any other condition. 

To find the probable length of the foetus at any given 
time, square the month of the pregnancy (up to five) 
and the result is the foetal length in centimeters. After 
the fifth month, multiply the number of the month by 
five. Thus: 

7th month x5=35 cm., the approximate length of the foetus 
at the lunar month. — (Hasse's rule.) 

The Mature Foetus. — Although subject to considerable 
variation, the foetus at term will weigh about seven and 
one-fourth pounds, and measure 50 cm. in length. The 
weight is far more uncertain than the length, and there- 
fore not so reliable as a sign of maturity. 

To obtain an estimate of the weight of the child at any 
given month of the pregnancy, the number of lunar 
months minus 2, is squared and divided by 2, and the 
result is the average weight of the child at that time in 
hundreds of grams. Thus: 

8th month -2=6. 6x6=36. 36-2=18, or in hundreds of grams, 
1800, the weight of the child.— (Tuttle 's rule.) 

Differences between the mature and immature 
foetus : 



Mature 

1. Skin smooth, plump, pink 
covered with vernix caseosa. 

2. Generous amount of subcu- 
taneous fat. 

3. Hair abundant and from 1 
to 2 inches long. 

4. Lanugo mostly absent. 

5. Nails project from finger 
tips. 



Immature 

1. Skin lax, wrinkled, dull red 
in color; little vernix case- 
osa. 

2. Subcutaneous fat scanty. 

3. Hair on scalp short. 

4. Lanugo present all over 
body. 

5. Short nails on fingers and 
toes. 



48 



OBSTETRICS FOR NURSES 



Mature (Cont'd.) 

6. Skull bones in contact ex- 
cept at fontanelles. 

7. Length 50 cm. 

8. Weight five to eight pounds. 

9. Cartilage in ear well de- 
veloped. 

10. Navel in middle of body. 

11. Testes have descended in 
the male, and the labia 
majora in the female usu- 
ally cover the labia minora. 

12. Moves and cries vigorously 
when born. 



Immature (Cont'd.) 

6. Skull sutures open. 

7. Moves and cries feebly when 
born. 

8. Weight less than live 
pounds. 



The Foetal Circulation. — The placenta is an organ 
of nutrition as well as respiration, and through the 
umbilical vessels the food materials are brought to the 
foetus and the Avaste products removed. 

Surrounded by the jelly of Wharton that fills out the 
cord, and running in and out between the two arteries, 
the umbilical vein passes into the foetal abdomen and di- 
vides into two branches, one, the larger, short-circuits di- 
rectly into the inferior vena cava. This branch is called the 
ductus venosus. The other joins the portal vein and 
passes through the liver, after which it also enters the 
vena cava. 

Thus the heart is fed with a mixed blood, part com- 
ing fresh from the placenta and part coming up from 
the lower half of the foetus. This blood is poured into 
the right auricle, where it becomes mixed again with 
the blood coming down from the upper pole of the foetus 
through the superior vena cava. 

Now a small part goes down into the right ventricle 
and is forced into the pulmonary arteries to supply 
the lungs. But the lungs are not functionating, hence 



PHYSIOLOGY 



49 




Fig. 23. — The foetal circulation. (Edgar.) 



50 



OBSTETRICS FOR NURSES 



the greater part is again short-circuited through the duc- 
tus arteriosus into the arch of the aorta, where it meets 
with the great volume of blood which passed over into the 
left auricle through the hole in the septum between the 
right and left auricles, called the foramen ovale, thence 
down into the left ventricle and out through the aorta to 
supply the rest of the fcetal body. 

With the exception of the ductus venosus and the 
ductus arteriosus and the foramen ovale, the circula- 
tion is the same as in the adult. 

The blood in the descending aorta again divides and 
part goes on to supply the lower extremities w hile the 
greater part leaves the internal iliac arteries by means 
of the hypogastric vessels and returns through the um- 
bilical arteries to the placenta for oxygenation. 

As soon as the child is born, the foetal structures are 
altered. The child breathes, the pulmonary circulation 
is established and the ductus arteriosus is closed. The 
placental circulation is abolished, and the ductus veno- 
sus and the hypogastric arteries are converted into solid 
fibrous cords. Owing to the immediate change of pres- 
sure in the auricles, the foramen ovale closes and the 
circulation assumes the adult type. 



CHAPTER III 



NORMAL PREGNANCY 

The entire body participates in the changes brought 
about by pregnancy. The hips and breasts become 
fuller, the back broadens, and the woman puts on fat. 
She becomes mature in appearance, but, of course, the 
phenomena connected with alterations in the breasts 
and genitals are most important, and late in pregnancy, 
most conspicuous. 

The uterus exhibits the most marked alteration. 
Prom an organ that weighs two ounces, it becomes the 
largest in the body, and increases in size from two and 
one-half or three inches to fifteen inches. The typical 
pear-shape becomes spheroidal near the end of the third 
month, becomes pyriform again at the fifth month, and 
continues thus until term. 

Up to the fourth month the Avails become thicker, 
heavier and more muscular, but as pregnancy advances, 
more and more tissue is demanded, until at the end, a 
muscle wall of only moderate thickness protects the 
ovum. Meanwhile the muscular functions of contrac- 
tibility and irritability are greatly increased. 

At the fourth month the womb, which has occupied a 
position of ante version against the bladder, rises out 
of the pelvis. It is now an abdominal organ and as it 
gets heavier and heavier, it rests a certain amount of 
its bulk on the brim of the pelvis. About the sixth 
month, the uppermost part of the uterus (fundus) is at 
the level of the umbilicus. At the eighth month, the 
fundus is found a little more than midway between the 

51 



52 



OBSTETRICS FOR NURSES 



umbilicus and the ensiform cartilage. About two w eeks 
before term, it reaches its highest point, the ensiform 
cartilage, and then sometimes sinks a little lower in 
the abdomen. 

The ovum, or egg, does not completely fill the uterine 
cavity at first, but grows from its side like a fungus until 




Fig. 24. — Gravid uterus at the end of the eighth week. (Braune.) 

the third month. Then the uterine cavity is entirely oc- 
cupied and thereafter the egg and the uterus develop 
at an equal rate. As the uterus rises in the abdomen, 
it rotates to one side, usually the right, forward on its 
vertical axis. 

The blood vessels and lymphatics also increase in size, 
number, and tortuosity. .Many of the veins become 



NORMAL PREGNANCY 



53 



sinuses as large as the little finger. This increased 
amount of fluid both within and without the uterus has 
a marked effect upon its consistency. The walls of the 
uterus, vagina, and cervix become softened, infiltrated 
and more distensible. There is also an increase in size 
and in number of the muscle cells. 

During pregnancy the uterine muscle exhibits a def- 
inite functional activity. Intermittent contractions oc- 
cur, feeble at first, but growing markedly stronger as 
pregnancy advances. These are the contractions of 
Braxton Hicks. They are irregular and painless, but 
can be felt by the examining hand. At term they merge 
into, and are lost in, the regular, painful contractions 
of labor. 

The breasts can not be said to be fully developed until 
lactation has occurred, nevertheless, the glands show 
pronounced changes as a result of marriage and preg- 
nancy. 

The size of the gland, as well as the size and appear- 
ance of the nipple and areola, varies greatly in different 
women ; but under the stimulation of pregnancy the 
whole gland enlarges, including the connective tissue 
stroma. 

About the fourth month a pale yellow secretion can 
be squeezed from the nipple. This is called colostrum. 
The pigmentation extends over a wider area and deep- 
ens in color, while the increased vascularity is shown 
by the appearance of the blue veins under the thin ten- 
der skin. Light pinkish lines sometimes radiate from 
the nipple. These are strise and are more evident in 
blondes. 

The milk comes into the breasts about the third day 
after labor, and normally continues to flow for six, to 
ten or twelve months. 



54 



OBSTETRICS FOR NURSES 



Why the pregnancy and labor induce such marked 
mammary activity is not known, but the fact is patent. 

The skin reacts both mechanically and biologically to 
the stimulus of pregnancy. 




Fig. 25. — Striae Gravidarum. (Edgar.) 



Striae Gravidarum. — Strise gravidarum appear on the 
abdomen similar to those observed on the breasts and 
are due to the same cause — mechanical stretching. 
When fresh, they are pinkish in color and variable in 
length and breadth, but attain the greatest size below 



NORMAL PREGNANCY 



55 



the umbilicus. Occasionally they extend to the thighs 
and buttocks. 

After labor, they become pale, silvery, and scar-like 
and are called linea albicantes. They are sometimes 
found in other conditions than pregnancy, such as tu- 
mors or ascites. 

Increased Pigmentation. — Pigmentation is not limited 
to the breasts. On the abdomen, a dark line will appear 
between the umbilicus and the pubes. This is the linea 
nigra, and it becomes most conspicuous in the latter 
half of pregnancy. In the groins, the axillae, and over 
the genitals, the deposit is common, and sometimes 
patches appear on the face, either disci ete or in coales- 
cence, to form a continuous discoloration, called chlo- 
asma; or when extensive, the "mask of pregnancy." The 
pigmentation is absorbed, or at least greatly dimin- 
ished, after labor. The sebaceous and sweat glands arc 
more active. 

The hair may fall out and the teeth decay. "With 
every child a tooth," is the cry of tradition. These 
changes are due to imperfect nutrition, or to the pres- 
ence of toxins in the circulation. 

Eruptions of an erythematous, eczematous, papular 
or pustular type are not uncommon ; and itching, either 
local or general, may make life miserable. 

The blood undergoes certain modifications that are 
fairly constant. The total amount is increased, but the 
quality is poorer, especially by an increase in water and 
white cells and a diminution of red cells. The amount 
of calcium is slightly increased and the fibrin is dimin- 
ished up to the sixth month, when it rises to normal 
again at term. 

The heart is slightly hypertrophied on the right side 
and blood pressure somewhat raised. A marked in- 
crease in blood pressure is suggestive of eclampsia. 



56 



OBSTETRICS FOR NURSES 



The thyroid gland enlarges frequently, both as a con- 
sequence of menstrual irritation and of pregnancy. 
Goiters may show an increase of development, which 
remains after labor. 

The urine is diminished in amount, but increased in 
frequency of evacuation. The bladder is more irritable 
during the first and last months, and micturition may 
be painful and unsatisfactory. The kidneys must be 
Avatched carefully during gestation. 

The nervous system is disordered in most women, but 
especially in those of neurotic tendencies. 

Irritability, insomnia, neuralgia of face or teeth, or 
perversion of appetite in the so-called "longings" are 
the more common manifestations. 

Cramps occur in the muscles of the legs, owing to 
varicose veins or pressure upon the lumbar and sacral 
plexus of nerves. 

The lungs are crowded by the growing uterus and the 
respiration interfered Avith. 

The liver is enlarged, but functionally it is less com- 
petent, and constipation is common. 

It is probable that most of the changes enumerated 
above are due to the circulation through the body of 
some definite product of fxrtal activity, Avhich is more or 
less toxic in character. The more pronounced effects of 
this toxin will be studied under the abnormal conditions 
of pregnancy. 

Generally, if the pregnancy is normal, the Avhole body 
responds to the stimulating influence. After the nau- 
sea and vomiting of the early months subside, the 
Avoman feels energetic and ambitious. She is eager to 
do something at all times and feels fatigue but slightly. 
Music, literature or houseAvork engages her attention 
and is zealously and joyfully practiced. The world 



NORMAL PREGNANCY 



57 



seems bright and the thought of her labor does not 
bring solicitude, but pleasant anticipations. The body 
fills out in all directions and the woman takes on the 
appearance of maturity. 

DIAGNOSIS OF PREGNANCY 

The presence of pregnancy is naturally determined 
by the recognition of those changes in the maternal 
system which the growing ovum produces. 

During the second half of the period the foetus can 
be made out distinctly by palpation, or by its move- 
ments, and the heart tones observed by auscultation. 

During the first half this is impossible and the diag- 
nosis must be made from subjective symptoms elicited 
from the patient and upon physical signs observed by 
the physician. 

It is of extreme practical importance to be able to 
recognize a pregnancy at all periods. The subjective 
symptoms of the first half are — amenorrhcea, morning 
sickness, irritability of the bladder, discomfort and 
swelling of the breasts, enlargement of the abdomen 
and quickening; but the appearance of any or all of 
these phenomena is not to be regarded as conclusive, 
but merely as a presumption that pregnancy exists. 
Either through ignorance, intent to deceive, or from 
pathological conditions, any or all of these symptoms 
may be present, but not until the tenth week are the 
changes in the uterus sufficiently definite to confirm a 
diagnosis unless the circumstances are especially favor- 
able. 

Amenorrhcea. — Cessation of the menses is practically 
invariable in pregnancy. One or two periods may occur 
after conception, but care must be used to exclude other 
causes of haemorrhage. Sudden cessation of the peri- 



58 



OBSTETRICS FOR NURSES 



ods in a healthy woman of regular habits who is not 
near the menopause, is strongly suggestive of preg- 
nancy. Why a developing ovum causes an immediate 
arrest of menstruation is not understood. 

Amenorrhcea may occur in consequence of chlorosis, 
heart disease, hysteria, tuberculosis, fright, grief, and 
some forms of insanity; a change from a low to a high 
altitude, or an ocean voyage not infrequently causes the 
flow to remain absent for one or more months. In 
addition to its value as a presumptive symptom, the 
amenorrhoea affords a common and convenient method 
of estimating the date of confinement. The method is 
fallacious but practical, and will be discussed later. 

Morning' Sickness. — This symptom is not invariable. 
It is most frequent in primiparas, but not so likely to 
occur in subsequent pregnancies. It usually appears 
about the second month, shortly after the first period 
missed. It varies in intensity. Some women have a 
little nausea on arising and no further trouble during 
the day, others are nauseated and vomit cither on ris- 
ing or after the first meal, and yet others after each 
meal; but the general health is not ordinarily affected 
and the tongue remains clean. Some cases are of ex- 
treme severity (hyperemesis) and will be discussed 
elsewhere. 

The morning sickness is probably toxic in origin. It 
must be remembered that chronic alcoholism is accom- 
panied by morning sickness, but with it the tongue is 
furred. 

Irritability of bladder is shown by a frequency of 
urination. It is caused by the congestion and stretch- 
ing of the tissues that lie between the uterus and 
bladder and hold them in relation to one another. After 
the third month an accommodation is established and 
the symptom does not reappear until late in pregnancy, 



NORMAL PREGNANCY 



59 



when the pressure of the heavy uterus tends to keep 
the bladder empty. If especially annoying, this irrita- 
bility may be much relieved by putting the patient in 
the knee-chest position night and morning. 

Enlargement of the breasts is common in primiparas, 
but this, with changes in the areola, may occur at men- 
strual periods in nervous women. Tingling, pricking 
and shooting sensations may also be noted. 

Enlargement of the abdomen is only noticeable to- 
ward the latter part of the first half, when the uterus 
rises out of the abdomen. 

Quickening means "coming to life," and refers to the 
first movements of the foetus that are felt by the mother. 
It is described as similar to the flutter of a bird in the 
closed hand. It is sometimes accompanied by nausea 
and faintness. Quickening usually occurs about the 
seventeenth week of pregnancy, and continues to the 
end. Gas in the intestines will sometimes simulate 
quickening. 

The movements are important in the second half as 
indicating that the child is alive. 

Physical Signs. — During the first weeks no conclu- 
sive changes occur that can be detected by examination, 
and unless conditions are especially favorable, the ear- 
liest time for the definite diagnosis of pregnancy is the 
eighth week. Previous to this it is presumptive only. 

At the eighth week, the breasts may show enlarge- 
ment and tenderness, with some secretion. In the multi- 
para, this sign has no significance. Secretion is present 
sometimes in the breast of nonpregnant women with 
uterine disease (fibroids). 

Examination of the abdomen at this time is of little 
value, but changes in the uterus can be detected by 
careful bimanual examination. It is needless to say 



60 



OBHTKTRICS FOR NURSES 



that all internal examinations should he made with the 
utmost care and gentleness. 

Softening of the lips of the os (Goodell's sign) may 
be found, but it must not be ccnfused with erosions of 
the os. The os of a nonpregnant woman feels like the 





Fig. 26. — Bimanual examination. (Edgar.) 

tip of the nose, and that of the pregnant woman like the 
lips. 

The increased size and globular shape must also be 
considered as confirmatory. 

Hegar's Sign.— The upper part of the uterus is soft 
and distended by the ovum, the lower part is sofl and 
not filled out by the ovum. Between the two is an 



NORMAL PREGNANCY 



(il 



isthmus that is compressible between the fingers of one 
hand in the vagina, and of the other upon the abdomen. 
When found, this sign is of great value. 

At the eighth week, pregnancy can be regarded as 
highly probable by the conjunction of the following 
symptoms and signs: Ameno'rrhcea, morning sickness, 
irritability of bladder, slight breast changes in primi- 
paras, lips of os externum softened, uterine body en- 
larged, softened, and nearly globular in shape, and 
1 tegar's sign. 

Abderhalden's test is a serum reaction based on the 
well established principle that the introduction into the 
blood of an organic foreign substance leads to the for- 
mal ion of a ferment to destroy it. Abderhalden's plan 
was to discover whether the blood of a pregnant woman 
contained a ferment capable of destroying placental 
protein. 11 is a very complicated test, and subject to 
many inaccuracies and numerous sources of error. At 
the same time, the main features of this reaction have 
been confirmed, and when it is worked out, it will be 
of immense value not alone in early uterine pregnancies, 
but in extrauterine pregnancy. This view very prop- 
erly demands that pregnancy be regarded as a parasitic 
disease. It is practicable as early as the sixth week to 
make a diagnosis, and it only fails in possibly ten per 
cent of the cases. The negative test is equally definite 
as eliminating pregnancy. 

Sixteenth Week. — Morning sickness and urinary 
symptoms have disappeared but amenorrhcea remains. 
Enlargement of the breasts is noticeable, as well as the 
increased pigmentation. The uterus begins to rise above 
the symphysis as an elastic, somewhat ill-defined, boggy 
mass. The cervix is softer. The characteristic dull 
lavender coloration of the vulvar mucous membrane is 



G2 



OBSTETRICS FOR NURSES 



now evident. It is due to the congestion and is called 
Jacquemins' sign. 

Two New Signs. — Irregular, painless contractions of 
the uterus (Braxton Hicks' sign), and ballottement. 

The contractions of Braxton Hicks now become more-, 
easily palpable. 

Ballottement consists in the detection in the uterus 
of a movable solid body surrounded by fluid. In a 
standing position, the foetus rests in the lower part of 
the uterus, just above the cervix. The woman stands 
with one foot on a low stool, and two fingers of one 
hand are pushed into the vagina until they touch the 
cervix, the other hand is placed on the fundus. A 
smart upward blow by the internal hand is transmitted 
to the fcetus, and it can be felt to leave the cervix, 
strike lightly the tissues underneath the external hand, 
and return to the cervix. It is simulated by so few 
things, and so rarely, that in practice it must be re- 
garded as a positive sign. 

During the second half, the subjective symptoms are 
of minor importance since unmistakable evidence is 
furnished by the physical signs. The symptoms of this 
period are mostly discomforts. Increased intraabdom- 
inal pressure brings on edema of the feet, cramps in the 
legs, varicose veins of the legs and vulva, dyspnoea, and 
palpitations. 

Twenty-sixth Week. — About the twenty-sixth week, 
or, at the end of the sixth calendar month, the hyper- 
trophy of the breasts, the presence of secretion, and the 
"marked pigmentation are unmistakable. The abdominal 
protrusion is now clearly visible, and the fundus will 
be found at the level of the upper border of the um- 
bilicus. 

Spontaneous foetal movements appear and may be felt 
by the palpating hand. 



NORMAL PREGNANCY 



Auscultation reveals the uterine souffle and the foetal 
heart sounds. The heart sounds and the foetal move- 
ments, when obtained by the observer, are positive signs. 

Uterine souffle is a soft, blowing murmur, synchro- 
nous with the mother's pulse. It is best heard at the 
lower parts of the lateral borders of the uterus. It is 




Fig. 27. — Abdominal enlargement at third, sixth, ninth, and tenth months of 
pregnancy. (Williams.) 



due to the passage of blood through the greatly dilated 
uterine arteries. It may be heard also in cases of fibroid 
tumors of the uterus. 

The foetal heart sounds are the most anxiously sought 
for of all the signs of pregnancy. They are conclusive. 
They not only determine the diagnosis, but afford valu- 



64 



OBSTETRICS FOR NURSES 



able information during labor, and nurse and student 
should lose no opportunity of becoming familiar with 
them. The heart tones can be heard as early as the 




Fig. 28. — Height of the uterus at various months of pregnancy. (P.unim.) 

twenty-sixth week, but they become more and more dis- 
tinct as pregnancy advances. They vary from 140 to 
160 beats to the minute at the twenty-sixth week, and at 



NORMAL PREGNANCY 



65 



term, from 120 to 140. When they rise above 160 or sink 
below 120, some danger threatens the child. The foetal 
heart tones have no significance as an indication of sex. 

Funic souffle is the sound made by the passage of 
blood through the umbilical cord when a loop acciden- 
tally lies under the tip of the stethoscope. It is syn- 
chronous with the foetal heart tones, but of no great 
practical importance when the heart tones can be ob- 
tained. 

Determination of the period to which pregnancy has 
advanced is sometimes important. This can be approx- 
imated by a calculation of the time that has elapsed since 
the last period, or from the date on which quickening 
has occurred. Measurement of the height of the fundus 
and comparison with such scales as Spiegelberg's, may 
be carried out, but it is not often required. 

A method of estimation in gross, that is approxi- 
mately correct, in many cases depends on the observa- 
tion of the steady growth of the womb. 

Thus, the uterus rises out of the pelvis at the fourth 
month, and may be found well above the symphysis 
pubis. At the fifth month the fundus is midway between 
the symphysis and the umbilicus. At the sixth month it 
reaches the umbilical level. At the eighth month it is 
a little more than midway between the umbilicus and 
the ensiform cartilage, which it attains in another month, 
the ninth. Then it usually sinks a little, especially in 
primiparas during the last two or three weeks. This is 
called lightening. 



CHAPTER IV 



HYGIENE OF NORMAL PREGNANCY 

The time of confinement can never be accurately de- 
termined, because the onset of labor is purely an 
accident, dependent on many factors. Furthermore, 
conception does not take place necessarily at the time 
of intercourse, and we have no means of knowing 
whether conception occurred just after the last period 
present or just before the first period missed. So there 
is always a possible error of three weeks. 

Pregnancy in the human family normally lasts from 
275 to 280 days, and the approximate date of confine- 
ment can be obtained by the following convenient rules : 

1. Take the first day of the last menstruation, count 
back three months and add seven days. 

2. Or, assuming that quickening occurs at the seven- 
teenth week, count ahead twenty-two weeks from the 
day on which quickening was observed. 

3. Or, count two weeks from the day of lightening. 

4. Or, with a pelvimeter, get the length of the foetus 
by Ahlf eld's rule (measure from symphysis to breech of 
child, subtract two cm. for thickness of abdominal wall 
and multiply by two. The result is the length of the child 
in centimeters) and compare with fifty centimeters, 
which is the average length of a mature child. After the 
seventh month, the child in utero grows at the rate of 
about 1 cm. a week (0.9 cm.). 

5. Or, by the tape, according to Spiegelberg's stand- 
ard of growth, as previously mentioned. 

The hygienic rules to be observed during pregnancy 

66 



HYGIENE OF NORMAL PREGNANCY 



67 



are founded on three basic principles: (1) To watch 
attentively the different organs and see that they func- 
tionate normally; (2) To eliminate all those conditions 
that favor the premature expulsion of the egg; and (3) 
To provide, so far as possible, for the normal gestation 
and the physiological delivery of the child. These fac- 
tors will be taken up in detail. 

The Diet. — The appetite is usually somewhat in- 
creased, but it is unnecessary to indulge the stomach on 
the ground that the mother "must eat for two." Long- 
ings, however, should be gratified so far as the demand 
is not for unwholesome things. Food should be simple 
and plainly cooked. Meat is permitted in moderation 
unless some organic change exists to contraindicate it. 
Rich pastries and gravies should be avoided, but cereals, 
fruits and vegetables should be used in abundance. It 
may be better to eat four times a day instead of three. 
Fluids should be taken freely, from one to two quarts 
daily. Milk is especially valuable, and alkaline, natural 
and charged waters, such as Vichy and seltzer, are use- 
ful. Wine, beer and other alcohols should not be taken, or 
if the patient is habituated to their use, the amount 
should be restricted on account of danger to the preg- 
nancy and danger to the child. 

In contracted pelves it is sometimes desired to fur- 
nish a special diet,, with the idea of controlling the size 
of the child (see Prochownick's Diet, p. 332) but this 
is an emergency. Certain books on maternity, designed 
for popular reading, advocate diets that are supposed, 
by depriving the child of lime salts, to keep its bones 
soft and make the labor easy. If it succeeds, the child 
will be injuriously affected. If it does not succeed, the 
claim is false. 

Exercise. — Exercise should be taken, but it should not 
be violent, nor attended by risk. Golf, swimming, ten- 



68 



OBSTETRICS FOR NURSES 



nis, dancing, horseback or bicycle riding and fast driv- 
ing in automobiles should be forbidden, lest abortion 
follow. General exhaustion must be avoided and all 
conditions that even approximate traumatism. Walk- 
ing and slow driving are best, and housework is excel- 
lent up to a mild degree of fatigue. Travel should be 
restricted. If exercise is not feasible, massage will 
furnish the required stimulation to the circulation. 
The menstrual epochs are peculiarly favorable to abor- 
tive influences. 

The Bowels. — Most women have a tendency to consti- 
pation during pregnancy. Many times this can be cor- 
rected by increasing the "roughening" in the food; 
more vegetables and fruits, bran bread and muffins, 
whole wheat bread, spinach, beans, carrots, turnips, 
peas and especially potatoes, baked and eaten, skin and 
all. Prunes, figs, and dates are valuable aids. Agar 
may be eaten three or four times daily. Russian oil 
(liquid petrolatum), taken in tablespoon doses three 
times daily, is an adjuvant, and finally, some form of 
cascara or aperient pill may be taken, if necessary. 

Violent cathartics should not be used at all, and 
enemas as little as possible; only when quick results 
are necessary. 

Heartburn. — Heartburn is a frequent complication, 
especially in the later months. It is due to an inordi- 
nate secretion of acid in the stomach. Soda mint tab- 
lets, bicarbonate of soda, and magnesia, in cake or as 
milk of magnesia, will relieve. The magnesia is also a 
laxative. 

The kidneys require particular care during preg- 
nancy, and in every case the urine should be examined 
monthly, up to the fifth month, and every two weeks 
thereafter, until the last six weeks, when a weekly test 
should be made. 



HYGIENE OP NORMAL PREGNANCY 



69 



The amount passed in twenty-four hours should be 
measured. Three pints is an average quantity. Al- 
bumin, sugar, and casts must be looked for and re- 
ported. Albumin may or may not be a serious symp- 
tom. Casts are significant of nephritis and indicate 
danger. Sugar may be lactose and be derived from the 
milk secreted in the breast. Edema of feet, hands and 
eyelids must always be investigated, with the possibil- 
ity in mind, of heart and kidney lesions. Blindness, 
dizzy spells, headaches and spots before the eyes are 
always alarming symptoms until their innocence is 
established. 

Through constant watchfulness of the urine, many 
cases of eclampsia may be averted. 

Bathing is more important in pregnancy than at other 
times. The more the skin secretes, the less the burden 
on the kidneys. The skin must be kept warm, clean, and 
active. Then again, during pregnancy the skin is often 
unusually sensitive and only the mildest soaps and bland- 
est applications can be used. The water must be neither 
hot nor cold, but just a comfortable temperature. Cold 
bathing, whether shower, plunge, or sitz, must be denied. 
Sea bathing is also unwise. The warm tub bath of plain 
water or with bran answers all conditions until the ex- 
pected labor is near, then the warm shower or sponge 
bath should be substituted, lest germs from the bath 
water enter the vagina. 

If the kidneys need aid, a hot pack may be used ; but 
in all cases, frequent rubbing of the skin with a coarse 
towel should follow the bath. 

The dress must be warm, loose, simple and suspended 
from the shoulders. To prevent chilling, wool or silk, 
or a mixture of both, should be worn next to the skin, — 
light in summer and heavy in winter. 

The patient must be sensibly clad in broad, loose, low- 



70 



OBSTETRICS FOR NURSES 



heeled shoes. There should be no constriction about 
chest or abdomen. Circular garters must not be worn. 
If a corset is insisted upon, it must support the abdo- 
men from below and lift it up. No corset is admissible 
that pushes down on the abdomen. This is especially- 
true if the woman has borne one or more children and 
has a pendulous abdomen. The breasts may get heavy 
and require the rest and ease supplied by a properly 
fitting bust supporter. 

Fainting 1 is an annoying symptom in some women. 
It may come when quickening is first perceived, or from 
the excitement of crowds, or from hysteria. It usually 
passes quickly. The pallor is not deep, the pulse is not 
affected, and consciousness is not lost, It does not af- 
fect the ovum. Heart trouble should be excluded, and 
the daily habits of dress, diet, and bowels investigated. 
Smelling salts will usually suffice for the attack. 

The abdominal walls may be strengthened by appro- 
priate exercise before and after gestation, so that the 
muscles will preserve their tone. After delivery nurs- 
ing the child will help greatly in the preservation of the 
waist line and figure, by aiding involution. 

About the seventh month in primiparas, the abdo- 
men gets very tense and in places the skin is stretched 
until it gives way and forms stria. This tightness can 
be relieved to a considerable degree by inunctions of 
cocoanut oil or albolene. 

Pain in the abdomen at this time may be due to me- 
chanical distention, to strain on the muscles, to stretch- 
ing of operative adhesions, to gas, constipation, or ap- 
pendicitis. The physician should be informed of it. In 
every case, constipation, swelling of feet, hands or eye- 
lids, blurring of vision, ringing in the ears, vomiting, 
persistent backache, or the passage of blood, no matter 
how slight, should be reported to the doctor. 



iiy<hi:ne of normal pregnancy 



71 



The Breasts. — There should be no pressure on the 
glands and they should be warmly covered. The nip- 
ples must be kept clean and soft by soap and water, and 
about a month before the labor is expected, the nipple 
should be anointed with albolene or cocoanut oil and 
rubbed and pulled for a few minutes every night. This 
removes the crusts and dried secretions that collect on 
the nipple and prepare it for the macerating action of 
the baby's mouth. No alcohol or strongly astringent 
washes should be used. Injuries must be avoided. If 
the nipples become tender they may be protected from 
external irritation by the lead nipple shield or by a 
wooden shield with a hollow center, such as WMliams 
recommends. 

Leucorrhcea. — This is one of the commonest discom- 
forts of pregnancy, and the sense of uncleanliness, if 
the discharge is excessive, as well as the resulting irri- 
tation, may demand attention. It must be kept in mind, 
however, that the normal vaginal discharge of a healthy 
pregnant woman is strongly germicidal and should not 
be douched away without definite indications. 

Vaginal douches of warm boric acid solution will do 
for cleanliness, but the douche bag must not be higher 
than the waist. Stronger and more antiseptic solutions 
are potassium permanganate 1 :5000, or chinosol 1 :1000. 
A suppository may be used, consisting of extract bel- 
ladonna, gr. ss; tannic acid, gr. v, and boroglyceride 
dr. ss. 

Sexual intercourse is distasteful to most pregnant 
women, but sometimes the inclination is intensified. 

Coitus often causes much pelvic discomfort and may 
be an influential factor in producing abortion. It should 
be forbidden during the early months, at all menstrual 
epochs, and for at least two weeks before labor. The 



72 



OBSTETRICS FOR NURSES 



uterus may be infected by germs beneath the foreskin 
and haemorrhage may follow the act if the placenta is 
low. In healthy persons, at the instance of the female, 
intercourse in moderation is permissible. 

The mental condition should be placid without either 
excitement or fatigue. Anxiety should be dissipated by 
cheerful company and surroundings. Judicious amuse- 
ment is desirable and a congenial occupation, but neigh- 
bors who tell frightful tales of disaster in labor, or 
nurses who relate the details of their critical cases, are 
equally to be avoided. 

Many women of neurotic temperament dread the la- 
bor desperately. They are sure that death impends and 
they dwell with tragic interest on the stories of compli- 
cated cases related by thoughtless or malicious neighbors. 
The nurse can do much to allay these apprehensions by 
cheerfulness, optimism, and gentleness. Her buoyant 
temperament will drive away the patient 's fears just as 
effectively as the assurances of the physician. 

Great allowances must be made for attacks of irrita- 
bility, for the changes going on in the woman's pelvis 
keep her in a capricious and whimsical condition. A 
good book to read at this time is, the "Prospective 
Mother," by Slemons. 

The subject of maternal impressions is the cause of 
much anxiety during pregnancy. It is safe to assure 
the mother that it is nearly impossible to mark her 
child by emotional stress. There is no demonstrable 
nervous communication between mother and child, and 
most of the deformities that occur and are attributable 
to shock, etc., can be explained by our knowledge of 
intrauterine changes. Furthermore, the same deformi- 
ties occur in lower animals, to which it is difficult to as- 
cribe such high nervous organization. 

Many of the birthmarks, supposedly due to shock, 



HYGIENE OF NORMAL PREGNANCY 



7:) 



occur too late in the pregnancy to affect the child, even 
if it were possible, for the child is completely formed be- 
fore the fourteenth week. 

The Determination of Sex. — It is not possible to know 
in advance of delivery whether the child will be a male 
or a female. It is equally impossible to determine or 
even to influence the sex of the coming child. Many 
theories have been advanced, and much talent has been 
wasted in trying to solve this problem. 

Reasoning by analogy from the facts obtained from 
lower animals, the sex of the child is unalterably de- 
cided the moment conception occurs. The responsibil- 
ity for the decisions seems to lie with the male cell. 
All we really know is that the sexes appear in the ra- 
tio of 100 girls to 106 boys. 



CHAPTER V 



ABNORMAL PREGNANCY 

After the diagnosis of pregnancy has been satisfac- 
torily established, no further internal examinations are 
necessary in the absence of special indications, until 
about the thirtieth week. 

At this time a series of complete physical examina- 
tions may be required to determine the presentation 
and position of the child, the presence and rate of foetal 
heart tones, the diameters of the head, the length and 
approximate maturity of the child, as well as the con- 
dition of the bony and soft passages of the mother. 

It is thus that an appreciation of the obstetrical prob- 
lem is secured and a course laid out for its successful 
solution. 

Pregnancy is not a disease, but a normal function; 
but the woman is exposed, nevertheless, to many grave 
risks that are peculiar to her condition and to many 
complications accidental or otherwise which are more 
serious on account of her pregnancy. 

The Toxaemias. — The growing ovum brings about 
changes in the maternal metabolism that are manifested 
by characteristic symptoms which in other better 
known conditions are recognized as due to toxaemia. 
Therefore, while there is no positive proof as yet that 
these symptoms, arising during pregnancy, are toxemic 
in origin, the evidence goes to show that they are ; and, 
therefore, should be classified as toxic. 

Postmortem findings in eclampsia and pernicious 

74 



ABNORMAL PREGNANCY 



75 



vomiting such as extensive thromboses, cell necrosis, 
and interstitial haemorrhages are very suggestive. 

Clinical findings in regard to the excretion of nitro- 
gen (urea, ammonia, uric acid, etc.), the occurrence of 
acidosis, elevation of blood pressure, fever, diminished 
excretion, coma and convulsions, all point to toxaemia. 

It is the minor disturbances, however, that the nurse 
will come in contact with most. They are nearly all 
toxaemic in origin, and a brief description of them must 
be given, together with suggestions for their manage- 
ment. 

Salivation or Ptyalism. — In the majority of cases, sa- 
liva is not especially noticeable ; but at times the secre- 
tion shows an enormous increase, and may even demand 
abortion. Patients will have saliva running constantly 
from the mouth. The amount may reach a pint or a 
quart a day, and the skin of the lower lip becomes 
greatly inflamed. 

The only satisfactory treatment is a rigorous milk 
diet on the theory that the disturbance is an intoxica- 
tion. In extreme cases abortion may be indicated. 

Gingivitis. — The gums may become inflamed, spongy 
and hsemorrhagic during pregnancy, usually in patients 
of low vitality. If a generous diet and astringent mouth 
washes do not relieve the condition, the milk diet 
should be considered. 

Toothache and Dental Decay. — The patient may be 
given hypophosphites, and the teeth should be put in 
good condition by a dentist. 

Constipation has already been referred to. Strong 
cathartics should be avoided lest abortion follow. 

Condylomata of pregnancy occur most frequently 
around the labia, perineum, and anus. They are wart- 
like growths that develop slowly or quickly and may 



76 



OBSTETRICS FOR NURSES 



remain discrete or cover the entire area with masses as 
small as beans or as large as cauliflowers, which in ap- 
pearance they much resemble. The etiology is obscure, 
but they are generally associated with irritating vagi- 
nal discharges, such as an old gonorrhoea. 

Treat in rut consists in stopping the discharge or neu- 
tralizing it, and in keeping the growths dry with a sali- 
cylic acid dusting powder. (See Therapeutic Index.) 

Pruritus is often distressing. The itching may be 
limited to the genitals or appear on other parts of the 
body. It may be due to the irritation of local discharges 
or to a condition of the nervous system, arising from 
toxaemia. Astringent douches and protective ointments 
will relieve some cases. 

Bromides and milk diet, bran or alkaline baths give 
good results, and local applications of sedative lotions 
and ointments containing menthol, carbolic acid or co- 
caine (cautiously) will aid. The woman in some in- 
stances becomes almost frantic, and tears at the vulva 
with her nails until it bleeds. 

The iodine treatment of Hensler is simple and often 
effective. If no skin changes are visible and but little 
leucorrhoea, the vulva is thoroughly prepared as for a 
vaginal operation, dried and painted with a 10 per cent 
solution of tincture of iodine. Generally one applica- 
tion suffices, but when the leucorrhoea is bad, it may be 
necessary to repeat the treatment on the third and fifth 
day thereafter. Between treatments, the vulvar sur- 
faces and even the vaginal walls (by insufflation) are 
kept dry with zinc oxide powder. If all measures fail 
and exhaustion is imminent, emptying the uterus may 
be advisable. 

Herpes is an inflammatory, superficial eruption, char- 
acterized by red patches, blisters, or pustules. It is 



ABNORMAL PREGNANCY 



77 



accompanied by burning, itching, and nervous depres- 
sion. The origin is probably toxic and the termination 
may be fatal. Milk diet, soothing lotions, and, if neces- 
sary, abortion, constitute the means of treatment. 

Areas of pigmentation (the chloasmata) are not ame- 
nable to treatment. They usually disappear after labor. 

Albuminuria of Pregnancy. — Albuminuria is so com- 
mon as to be almost physiological When the amount 
of albumin is small. When the amount of albumin in 
the urine is large, it may be due to pre-existing disease, 
which is first discovered when the urinalysis is made 
during pregnancy. (Chronic nephritis?). 

If it makes its debut during gestation and continues 
as a mere trace without casts, it is spoken of as the al- 
buminuria of pregnancy, but the patient must be watched 
with great care, since the albuminuria may be a pre- 
monitory sign of eclampsia. 

Albuminuria and eclampsia must be considered to- 
gether, because, while the two conditions may exist 
separately, they are most frequently associated, and it 
is believed that they have a common causation. It is 
true that most cases of albuminuria terminate favorably, 
yet the higher the albumin content, the greater the 
danger of eclampsia. 

Albumin appears in the urine in from three to five 
per cent of all pregnancies. It is more common in the 
latter half of gestation and the attacks differ greatly 
in severity. 

Symptoms. — In the early stages the urine shows an 
abundant, pale fluid of low specific gravity. 

The seriousness of the case is generally indicated by 
the amount of albumin, although this is not a reliable 
guide as to the danger of eclampsia. Casts and red 
and white blood corpuscles are occasionally found. The 



78 



OBSTETRICS FOR NURSES 



output of urea usually remains normal, but diminution 
usually occurs in connection with eclampsia. Anaemia 
and anasarca are common, but it is a hopeful clinical 
sign that the cases of extensive edema rarely develop 
eclampsia. 

In albuminuria of pregnancy there is a large foetal 
mortality which, to a degree, is independent of eclampsia. 
The infant dies in utero or is born feeble, or prematurely. 

Eclampsia is the sudden appearance of convulsions 
in the course of pregnancy. It may precede, follow, or 
accompany albuminuria. It occurs rarely in the ab- 
sence of albuminuria in a woman who was apparently 
in good health. The two phenomena are best explained 
as a consequence of toxaemia due to poisons at present 
unidentified. 

Treatment of the albuminuria is treatment for im- 
pending eclampsia. Regular examination of the urine 
is indispensable. The presence of albumin suggests 
toxaemia. The daily output of urine and the output of 
urea must be compared, for a fall in urea is a premoni- 
tory sign of eclampsia. The bowels and the skin should 
be stimulated, respectively, by saline cathartics, hot 
baths and packs. The digestive organs must be spared 
as much work as possible, especially the liver. Water 
is given in abundance, and milk is the staple diet. Kou- 
miss, butter milk and ice cream may be allowed. As the 
patient improves, vegetables are allowed. The food 
should be salt-free; and alcohol, as well as rich, indi- 
gestible things should be forbidden. In the milder cases 
boiled fish and a little chicken may be permitted. 

The course of the disease and the condition of the 
patient is determined by frequent examinations of the 
urine, while in all serious cases an examination of the 



ABNORMAL PREGNANCY 



79 



fundus of the eye must be made to detect a possible 
albuminuric retinitis. 

The treatment of eclampsia will be considered un- 
der the complications of labor, where the attack usually 
begins. 

Pyelitis of pregnancy is an acute, and rarely, a chronic 
infection of the pelvis of the kidney, due to the Bacil- 
lus coli. It usually appears after the fourth month 
(fifth to eighth) and attacks by preference the right 
side. Extension to the kidney substance, ureters, and 
bladder is occasionally observed. 

Symptoms. — Sudden, acute abdominal pain, at first 
diffuse, but after a few hours, becoming localized in the 
right side, and on this account is often confused with 
appendicitis, especially as vomiting is not infrequent. 
A chill may mark the onset and the temperature rise to 
103° F. or 104° F. The bowels are constipated, the 
tongue coated, and there is tenderness over the kid- 
ney. The urine is scanty, turbid, slightly albuminous 
and contains pus and epithelium in the urinary canal. 
A culture reveals the bacillus which has obtained access 
to the kidney, either by extension of the ureter from the 
bladder, by direct invasion of the tissues from the ad- 
jacent colon, or through the circulation. 

Treatment. — The diet should be fluid and mostly milk, 
the bowels should be moved freely and frequently. The 
urine is alkalinized with sodium citrate, since the Bacil- 
lus coli lives only in an acid medium. As the symp- 
toms subside, urotropin may be administered. If the 
patient does not improve within two weeks, abortion 
must be seriously considered. Nephrotomy is not to be 
thought of unless abortion has failed. 

Hyperemesis Gravidarum. — The nausea and vomiting 
of pregnancy is so usual as to be regarded as normal. 



80 



OBSTETRICS FOR NURSES 



It usually ceases from the fourth to the fifth month 
spontaneously; has no ill effect upon the ovum, and 
may respond readily to treatment. 

Hyperemesis comes on at the same period and ex- 
hibits all stages of violence, from the mild form above 
described, to cases that end fatally. 

Three classes of this serious disorder may be distin- 
guished as associated (Eden), neurotic, and toxaemic 
vomiting. 

Associated vomiting is the vomiting that comes with 
gastric ulcer or cancer, chronic gastritis, cirrhosis of 
the liver, and cerebral disease. These conditions must 
be excluded in diagnosis. 

Neurotic vomiting — severe and persistent nausea and 
retching — is common in pregnant women of the nervous 
type. It does not lead to loss of flesh ordinarily; the 
urine is somewhat diminished in quantity from the 
lack of fluids, but the amount of nitrogen excreted re- 
mains normal. This is important. 

Toxemic vomiting includes a small but very import- 
ant class of cases, for all are severe and intractable and 
some end in death. 

Clinical Features. — The normal nausea and vomiting 
may seem unusually severe. It persists and gets worse. 
Then vomiting occurs when no food is taken and nothing 
is held on the stomach. The vomit is stained with bile 
or blood. The tongue remains clean, and the general 
condition is good. 

Next, weight is lost and the pulse quickens. A per- 
sistent pulse of over 100 is serious. The tongue be- 
comes coated, sordes develops, sleeplessness and muscu- 
lar twitching appear, and the patient complains of epi- 
gastric pain. Abortion may now occur and the condition 
clear up. 



ABNORMAL PREGNANCY 



Si 



In its final stage, the urine becomes scanty and albu- 
minous, icterus may appear and the temperature rise to 
100° F. or more, though sometimes it is subnormal. The 
pulse may go to 120. Delirium and coma supervene, 
and emptying the uterus is of no value. Fifty per cent 
of these bad cases die. 

The especially prominent points to be noted are the 
urine, which shows acetone, albumin and blood, either 
one or all, as well as an increased amount of ammonia. 
A persistently rapid pulse, marked loss of flesh, coated 
tongue, jaundice and delirium are regularly present. 

Treatment. — Organic disease must be excluded and a 
diagnosis of pregnancy strongly evident. 

For the neurotic type, the patient must be segregated 
from her friends, and a competent, cheerful nurse put 
in charge. A cool, darkened room is best. If the pa- 
tient can be transferred to a hospital, the results are 
more satisfactory. Here the isolation from external 
interests and irritations can be made complete: The pa- 
tient does not talk, even the nurse comes with food, at- 
tends to the obvious necessities, and departs in silence. 
Once a day a sedative bath is given (see Baths, p. 325) 
and medication in kind and frequency as the conditions 
demand. 

In any case, the patient should be put to bed and fed 
carefully every two or three hours on milk, peptonized 
food or barley water. If this is not retained, albumin 
water may be given for twenty-four hours at regular 
intervals, or rectal alimentation may be tried after stop- 
ping all foods by mouth. Iced champagne, seltzer or 
Vichy, either alone or with milk, may be tried. A dry 
diet is sometimes effective, rusk, toast, toasted shredded 
wheat biscuit, crackers, etc., taken early in the morn- 
ing, as one eats cheese. No exercise is permitted ex- 



82 



OBSTETRICS FOR NURSES 



cept such muscular and nervous excitation as may be 
derived from massage or the sedative bath. 

Drugs are sometimes of great value — the bromides, in 
full doses, or 1 m. doses of tincture of iodine, well diluted, 
every hour; or bismuth with hydrocyanic acid; or co- 
caine or oxalate of cerium. Occasionally good results are 
reported from a capsule of pepsin, 2 gr. and *4 gr- 
silver nitrate given just before meals; and adrenalin in 
10 drop doses may be considered. Extract of corpus 
lutea has been tried by Hirst with favorable results. 

Sinapisms to the epigastrium and ice bags to the spine 
have been found useful, and Mashing out the stomach 
is efficient at times. In washing out the stomach, be sure 
the stomach tube is iced before it is introduced. 

When the case gets worse in spite of treatment and 
acidosis supervenes, bicarbonate of soda may be given 
in sixty grain doses every four hours, by rectum, if 
necessary, until the urine gives an alkaline reaction. 

Glucose as a readily assimilable carbohydrate may 
be given in doses up to 10 oz. of a 6 per cent solution 
(Eden) or sugar infusions by rectum, 1000 c.c, in twen- 
ty-four hours by drop method. 

The obstetric treatment is the emptying of the uterus. 
To be effective the abortion must be done before the 
condition of the patient is desperate. It is most favor- 
able before the febrile stage. If the vomiting persists 
in spite of treatment and is accompanied by emaciation, 
a pulse of over 100, albumin in the urine, with an in- 
crease of the ammonia output, the pregnancy should be 
terminated at once. If the patient can not go to a 
hospital, the nurse should prepare the room as described 
for operations. 

After emptying the uterus, the vomiting usually 
ceases but much labor is thrown upon the nurse in sup- 



ABNORMAL PREGNANCY 



S3 



plying nourishment and caring for an exhausted and 
whimsical patient, 

The back must be inspected daily for decubitus (bed 
sores) and her position changed frequently. A daily 
rub with alcohol and water (50 per cent) followed by an 
oil inunction will be valuable. The teeth and gums 
should be cleaned with gauze, wrapped around the 



finger and dipped in solution of boric acid. No brush 
should be used. 

Multiple Pregnancy.— Twins occur about once in 
ninety labors, triplets, once in seven thousand. 

Heredity and multiparity seem to be the only recog- 
nized predisposing factors. The more pregnancies a 
woman has, the more liable she is to have twins. 

Twins may occur through a division of the primitive 
cell through the fertilization of two ova from the same 




Fig. 29. — Twins. (Lenoir and Tarnier.) 



84 



OBSTETRICS FOR NURSES 



or different ovaries, or by fertilization of a single ovum 
having two nuclei. (See Fig. 13). The former are 
called binovular twins, and may or may not be of 
the same sex. The latter are called uniovular twins and 
are always of the same sex. Twins are usually some- 
what smaller than a single child, and frequently asso- 
ciated with hydramnios. Binovular twins have separate 
placenta? and uniovular twins have one placenta, with 
separate cords. 

Twin pregnancies usually go into labor earlier than 
the single child, possibly on account of the over-disten- 
tion of the uterus. 

The diagnosis is occasionally difficult and at other 
times easy. Two sets of heart tones must be distin- 
guished and differentiated by their variation in fre- 
quency, heard at the same time by different observers. 
The presence of twins may be strongly suspected also 
when the external measurements of child and uterus 
greatly exceed the average. In such cases a systematic 
and persistent search must be made for the two foetal 
heart tones. 

The delivery is generally uncomplicated, unless the 
chins become locked. 

Displacements of the Uterus. — In most cases displace- 
ments of the uterus are a consequence of conception in 
organs that are previously retroflected or retroverted. 
They rarely produce symptoms until the end of the third 
month, when the attention is directed to the bladder. 
There may be absolute retention or a constant drib- 
bling from a full bladder (ischuria paradoxa), possibly 
associated with pain. If recognized early, an attempt 
should be made to replace the uterus by posture (knee 
chest) and when replaced, to hold it by pessary or tam- 
pon. The prone position in bed will aid. 



ABNORMAL PREGNANCY 



85 



After retention has occurred, the patient should be 
put to bed and the bladder catheterized regularly every 
eight or ten hours for three or four days. As a rule, the 
organ will rise spontaneously into the abdomen. If it 
does not, it is probably incarcerated under the promon- 
tory, and the physician must try to replace the uterus 
by manipulation or by continuous pressure, but in bad 
cases, he Avill empty the uterus before the condition of 
the patient becomes too serious. 

In multiparas with weak abdominal Avails, or women 
with spinal curvature or contracted pelves, the uterus 
may fall forward and, passing between the recti mus- 
cles, continue to drop until the fundus lies lower than 
the symphysis pubis. 

Management, until labor occurs, may be made more ef- 
fective by using' a strong, well-fitting abdominal bandage. 

Malformation of the uterus may possess an obstet- 
ric interest at time;. The double uterus (uterus didel- 
phys) and the uterus with a rudimentary horn (uterus 
bicornis) are examples. These are congenital condi- 
tions, due to imperfect development, and pregnancy may 
take place in one or both sides. If in one side only, the 
other half will also exhibit the softening and other 
changes as in normal cases. Binovular twins may be the 
result of a pregnancy in each side. 

Pressure Symptoms. — Edema of legs and sometimes 
of the vulva occurs during the last trimester. It is due 
to increased intraabdominal pressure and to direct in- 
terference with the return circulation by the pressure 
of the heavy uterus on the iliac veins at the brim of the 
pelvis. The urine should be examined for albumin and 
the patient put in the horizontal position if the edema 
is troublesome. 

] ^ricose veins of legs and vulva may cause much dis- 



86 



OBSTETRICS FOR NURSES 



tress. The limbs should be bound with flannel spirals 
or with rubber bandages in the recumbent position, or 
elastic stockings may be obtained. Operation during 
pregnancy is not to be considered. The vulva can only 
be relieved by a double bandage, which is sewed at the 
point where it crosses the vulva, and buckled or tied 
to a waistband above the hips, both before and behind. 
This brings support to the vulva. If the veins rupture, 
the part should be elevated and compressed with an asep- 
tic pad. 

Hcemorrhoids may either appear or grow worse late 
in pregnancy. If they protrude, they should be replaced. 
Ointments and iced applications may be used and the 
bowels kept loose. 

Cramps may occur in the muscles of the legs, due 
sometimes to the varicose veins and sometimes to pres- 
sure on the lumbosacral plexus. 

Moles. — Mole is the name given to an ovum which is 
destroyed by disease of its coverings during the early 
months of gestation. Tavo kinds are known, the blood 
mole (carneous mole, fleshy mole, or haematoma mole) 
and the hydatidiform mole (vesicular mole). 

The blood mole results from progressive or recur- 
rent slight haemorrhages during the first three months 
of pregnancy, but haemorrhages insufficient in quantity 
to produce an abortion. The blood forms a clot, which 
may be retained for several months and become solidi- 
fied. 

Hydatidiform mole is a disease of the young chori- 
onic villi, characterized by the growth of an immense 
number of irregular clusters and chains of grape-like 
cysts from the very minute to bodies four-fifths of an 
inch in diameter. The causation is unknown. 

Both forms occur in the first half of the pregnancy 



ABNORMAL PREGNANCY 



87 



and are characterized by undue enlargement of the 
uterus and hemorrhagic discharge. 

Diseases of the Membranes. — Hydramnios, or polyhy- 
dramnios, is the name applied to the condition where an 
excess of liquor amnii is formed. The amount normally 
present varies, but anything in excess of four pints 
could be called hydramnios. Six gallons have been re- 
ported. Since the source of the liquor amnii is not 
positively known, the etiology of hydramnios must be 
equally obscure. 

It is occasionally associated with morbid conditions of 
the mother, such as hepatic or cardiac dropsy, but more 
frequently with developmental anomalies of the foetus. 

Since the mother is usually healthy and the foetus fre- 
quently deformed, the theory is advanced that the dis- 
ease is foetal in origin. It frequently occurs with twin 
pregnancies, and in the first months it is most plausible 
that the liquor amnii is in some way derived from the 
foetus. 

The disease is more common in multiparas. It is 
generally slow in onset, but it may be acute, and an 
immense amount of fluid may be formed in a few weeks. 

The symptoms are those due to pressure from the ex- 
tremely large uterus. 

The treatment, if interference with heart or lungs 
becomes pronounced, is puncture of the membranes. 
The child need not be considered for it is usually dead 
or deformed. 

Oligohydramnios is the condition where the liquor 
amnii is deficient in amount. It gives no maternal 
symptoms, but it is the cause of many birthmarks and 
foetal deformities (club-foot, spinal curvature, wry-neck, 
ankylosis of joints). 

Amniotic adhesions are usually associated with oli- 



88 



OBSTETRICS FOR NURSES 



gohydramnios and cause deformities by amputation of 
limbs, strangulation of cord, and production of six 
fingers. 

The placenta may show anomalies of size and shape. 
Thus, there may be two lobes, or three. There may be 
the main placenta and a small out-lying mass con- 
nected by membrane and vessels with the larger seg- 
ment. The cord may be inserted in the middle or at 
the edge and yellowish-white masses called infarcts may 
be found in its substance. 

Unusual size and weight of the placenta are sugges- 
tive of syphilis. 

Abnormal conditions of the foetus may arise from pri- 
mary or transmitted disease or from errors of develop- 
ment. The developmental errors may be monsters, hy- 
drocephalus spina bifida, etc., which may not influence 
the pregnancy. The most commonly transmitted dis- 
ease is syphilis, which may produce abortion, prema- 
ture labor, or a child born with syphilitic sRin changes 
on palms and soles, as well as internally. 



CHAPTER VI 



ABNORMAL PREGNANCY (Cont'd) 

Extrauterine Pregnancy. — This is a pregnancy which 
occurs outside the uterus, and while the event usually 
happens in the tube, cases have been reported where 
the egg developed in the ovary or abdomen. 

The ovum, owing to some delay in passage to the 
litems, is fertilized either in the ovary or in the tube, 
and by reason of a chronic inflammation of the tube 
or pelvis, or of over-growth does not succeed in reach- 
ing the uterus at all. 

As the ovum develops, the tube expands, but it does 
not possess the power of growing into a large organ 
like the uterus, hence a sudden jar, a strain, or a blow 
may cause it to rupture and discharge the egg into the 
abdomen (ruptured tubal pregnancy) or force it out 
through the end of the tube (tubal abortion). 

This phenomenon may be accompanied by a severe or 
even fatal haemorrhage; or the prostration may pass off 
in a few days or weeks, and leave the patient well. 

In the early stages the ovum is absorbed, but after the 
pregnancy becomes more advanced, it may remain as a 
tumor, or require an operation for its removal. 

Infection may occur and the mass ulcerate its way 
into neighboring organs (rectum, vagina, or bladder) 
and discharge itself in a long, suppurative process. 

Most cases of ectopic (extrauterine' gestation present 
definite and even dangerous symptoms between the second 
and fourth month. The s!j»ipto))>s are those of pregnancy, 
together with irregular haemorrhages from the uterus, 

89 



90 



OBSTETRICS FOR NURSES 



which may result in the expulsion of pieces of tissue or 
of membrane. Besides this, there is a vomiting and 
acute irregular pain on one side, associated with a sense 
of fullness. Such symptoms should be brought to the 
attention of the physician, who will learn the true con- 
dition of the pelvis by internal examination, conducted 
as gently as possible so as not to produce rupture. 

If rupture occurs, it will be ushered in by a sharp 
lancinating pain on one side, followed by faintness, 
nausea, vomiting, prostration, rapid pulse, sighing 




Fig. 30. — Diagram representing the sites for the various forms of tubal 
pregnancy. 1, interstitial pregnancy; 2, isthmial pregnancy; 3, ampullar 
pregnancy; 4, infundibular pregnancy; 5, tubo-ovarian pregnancy. (Gil- 
liam.) 

respiration, and collapse. The temperature is sub- 
normal and death may occur in a few hours, unless an 
operation is done. 

In cases of tubal abortion (where the ovum escapes 
through the end of the tube) the symptoms are very 
similar, but the patient soon rallies and gradual re- 
covery takes place. 

If the diagnosis is made before rupture or abortion 
the treatment is laparotomy. If rupture occurs, the 



ABNORMAL PREGNANCY 



01 



laparotomy must be done immediately to check the 
haemorrhage, which threatens the life of the patient. In 
tubal abortion, if the diagnosis is certain, some delay 
may be permitted under extreme watchfulness of the 
nurse and physician. In such case, the nurse will 
keep the patient absolutely quiet and forbid exertion of 
any kind. 

If operation is necessary, the utmost gentleness must 
be used in preparing the abdomen. The tincture of 
iodine application to the site of the incision is sufficient 
preparation, and, of course, an abundance of sterile 
gauze, cotton, and towels should be supplied, as in every 
case where laparotomy is done. 

If the rupture occurs while the nurse is present, the 
doctor should be notified at once, and if not at home, 
another doctor should be summoned. Meanwhile, the 
nurse prepares the room, solutions and utensils for an 
abdominal operation. Immediate incision to check the 
haemorrhage and remove the mass offers the greatest 
safety. 

The after-care is the same as for any laparotomy, 
with the additional duty of making up the lost blood 
as soon as possible by nourishing foods, normal saline 
solution by rectum, and, if necessary, by hypoder- 
moclysis. 

Acute fevers are a serious complication of pregnancy 
on account of the danger of abortion or premature 
labor, which may come on either from the associated 
high temperature or from the transmission of the dis- 
ease to the ovum. 

The following diseases are known to affect the foetus 
in utero: cholera, yellow fever, small pox, scarlet fever, 
typhoid, measles, erysipelas, meningitis and syphilis. 



92 



OBSTETRICS FOR NURSES 



CHRONIC INFECTIONS 

Tuberculosis does not affect fertility or the course 
of the pregnancy, but the progress of the disease is 
hastened, and the maternal death accelerated. 

The question of artificial abortion in the early months 
must be seriously considered, and if the case goes on 
to term, the child must not be nursed or cared for by 
the mother. 

Syphilis is the most frequent systemic cause of the 
interruption of pregnancy. It is a blood disease, due to 
an organism called spirochseta pallida, and it appears 
in three distinct stages. The first is the primary stage, 
Avherein a hard, nodular ulcer appears on some part of 
the body, as the vulva, lips, gums, tonsils, or hand. It 
is not always venereal in origin. The second stage be- 
gins six or eight weeks after the sore, and is marked by 
a general eruption of red spots, chronic sore throat, fall- 
ing hair, and rheumatic pains in the joints. The third 
stage is the name given to the later conditions of the 
disease which affect the bones, blood vessels, and ner- 
vous system. 

Infection of the ovum may usually be traced to the 
father, who may transmit syphilis at any stage of the 
disease. In the third stage, the child alone will be in- 
fected; the mother escapes. 

The mother may or may not transmit the disease, 
depending on the period of pregnancy wherein her in- 
fection occurs. If she gets the disease at, before, or 
just about, the time of conception, she will abort three 
times out of four, and the ovum will show definite 
lesions. If infected later, abortion occurs less fre- 
quently; and if the disease is contracted late in preg- 
nancy, the child may be born apparently free from in- 
fection. 



ABNORMAL PREGNANCY 93 

Symptoms. — A child with congenital syphilis will show 
the eruption of coppery spots, blisters on palms and soles, 
deep cracks on the feet, snuffles, cracks and ulcers around 
the mouth and rectum, and the weakly, marasmic con- 
dition of the body. 

The diagnosis in suspected cases can be rendered more 
certain by the Wassermann reaction. This is a labora- 
tory test of the blood which should always be made be- 
fore a wet nurse is allowed to nurse a child, or before 
a suspected child is nursed by a clean woman. In all 
cases of transfusion of blood, it is imperative. 

Treatment. — Antisyphilitic treatment of an infected 
mother or child by salvarsan, mercury, and potassium 
iodide must be carried out vigorously in all cases. 

The syphilitic patient must be prevented from spread- 
ing the infection by having dishes and utensils of her 
own, which are kept sterile. Discharges are collected 
and burned, and the nurse in charge of these cases must 
carefully cover her hands with rubber gloves, and see 
that all cracks and fissures are properly protected from 
contact with sources of infection. 

Gonorrhoea is an acute or chronic disease of the mu- 
cous membranes due to a germ called the gonococcus. 

Beginning with a sharp inflammatory disturbance of 
the urethra or vagina, it may pass slowly up through 
the genital passage and produce chronic and permanent 
disabilities, such as sterility, pus tubes, and pelvic peri- 
tonitis. 

The symptoms are painful urination, painful inflam- 
mation of the vagina, with a purulent discharge. Dur- 
ing pregnancy all these symptoms are intensified, and 
warty growths (condylomata) may appear on the vulva. 

If infection occurs after pregnancy has begun, the 
course of the gestation is rarely affected, as the uterus 
is closed to germ invasion. During delivery, however, 



94 



OBSTETRICS FOR NURSES 



there is a serious danger of infection of mouth or eyes 
of the child if they come in contact with the discharge. 

Prophylaxis.— The eyes at birth must be immediately 
instilled with a drop or two of 1 per cent solution of silver 
nitrate in water. This is not neutralized by normal saline. 
Great care must be used that the discharge does not come 
in contact with the eyes of the mother or attendants, lest 
infection follow. 

Treatment. — Scrupulous cleanliness must be observed. 
Douches of potassium permanganate, 1:5000, or painting 
the vagina with iodine or solution of silver nitrate, or 
suppositories of argyrol or protargol furnish the best 
means of treatment before labor. 

Neither syphilis nor gonorrhea is necessarily caused 
by venereal infection. They may be spread by barbers, 
dentists, physicians, and nurses, — by anyone who is un- 
clean; and may be acquired innocently everywhere. 

These diseases should not be discussed by the nurse or 
physician except with the patient. Certainly nothing 
from the sick room should be repeated elsewhere. 

The valves of the heart are not uncommonly found to 
be diseased in pregnancy, the mitral being the most 
often affected, either as an insufficiency or as a stenosis 
(a narrowing of the mitral opening). Mitral stenosis 
is the most serious of all heart complications of preg- 
nancy, and where this is present, a woman should be 
advised to avoid conception. 

In other mitral lesions, many pregnancies may be 
successfully passed, if compensation is maintained ; but 
every one brings further damage to the already weak- 
ened heart, and reduces its reserve of force. If the heart 
breaks down early in pregnancy, and does not respond 
to medication, abortion should be induced. In the sec- 
ond half of pregnancy, the mother should be given the 
prior chance, but the child should be saved, if possible. 



ABNORMAL PREGNANCY 



95 



Renal diseases, such as nephritis, may not only induce 
abortion by destroying the foetus, but the kidney lesion 
may be greatly aggravated by the pregnancy. The most 
careful observation of the patient's condition, the regu- 
lar examination of the urine, and the scientific manage- 
ment of the diet is necessary to relieve the work on the 
kidneys and keep the patient in a moderate degree of 
health. 

It is the duty of the nurse to protect her patient 
against fatigue and chill, and to see that the proper diet 
is followed ; but other symptoms, such as headache and 
disturbance of vision and developing edema, must be 
noted and reported to the physician at once. 

Diseases of Liver. — Acute yellow atrophy is a rare 
condition, which, for reasons unknown, is promoted by 
pregnancy. 

The symptoms are intense headache and pain in the 
abdomen, possibly accompanied by vomiting and purg- 
ing, which are soon followed by coma. There is generally 
a certain amount of jaundice. The urine is diminished 
in amount and contains albumin, casts, and sometimes 
blood. There is no known treatment, and the end is 
death. 

Diabetes is seldom found associated with pregnancy. 
Its presence is unfavorable to conception and to gesta- 
tion. Mother and child are both less secure. Abortion or 
premature labor is the rule. 

The haemorrhages of pregnancy in the first half gen- 
erally mean abortion, and in the last half, either placenta 
praevia or premature detachment of the normally im- 
planted placenta (see p. 228). 

Abortion is the expulsion of the ovum before the 
foetus is viable, that is, before it is capable of maintain- 
ing life after birth. This means the twenty-eighth week, 
or the seventh month. Subsequent to the seventh month, 



96 



OBSTETRICS FOR NURSES 



the interruption is called premature labor. Abortion is 
a miniature labor, consisting of a stage of dilatation, a 
stage of expulsion, and a stage of involution. 

The interruption of the pregnancy may occur spon- 
taneously or be induced. In spontaneous cases the 
causes may be sought in diseases of the ovum, or in the 
mother, in injuries to the uterus or its contents, and 
such systemic affections as syphilis, Bright 's disease, 
alcoholism, lead poisoning, etc. 

Abortions happen about once in every five or six preg- 
nancies, and more frequently at the third month than 
at any other time. 

The symptoms are haemorrhage and pain. The dangers 
are haemorrhage and infection. 

Infection is most common and most serious in abor- 
tions that are brought about mechanically. 

Haemorrhage, in some degree, is an invariable symp- 
tom, which has its origin in the separation of the ovum 
from the uterine wall. Haemorrhage from the uterus is 
serious at whatever stage of pregnancy it appears. 

The duty of the nurse is to put the patient in a cool, 
dark room, on her back, elevate the foot of the bed, put 
ice bags on the lower abdomen, and summon the at- 
tending physician, with the hope that an abortion can 
be averted. Bromides and opium are the drugs most 
to be relied upon. Opium may be given in suppository, 
1 grain night and morning. 

If the haemorrhage is alarmingly profuse and the 
nurse is skillful and clean, under exceptional circum- 
stances she may pack the vagina with sterile cotton 
Avhile waiting for the doctor. Then the room should be 
set for operation. 

Dead Ovum. — The ovum may be discharged in pieces 
or in a single complete mass. 

The egg may die at any period of the pregnancy, and 



ABNORMAL PREGNANCY 



97 



be discharged in a few hours, or it may not be expelled 
for weeks, if at all. Foetal death in the uterus may 
have its cause on the paternal side in a father too old or 
too young, or affected with such diseases as diabetes, 
nephritis, tuberculosis, syphilis, or . chronic lead poison- 
ing; on the maternal side, the same diseases, plus cancer, 
anaemia, insufficient food, and inflammation of the 
uterus ; on the part of the embryo, syphilis or any trans- 
mitted or primary disease of the ovum. 

The results of retention of the dead ovum vary with 
the case. Infection of the ovum is rare, except where 
the membranes have ruptured and an open channel ex- 
ists. No harm follows the death of the foetus, except 
in the presence of infections, all other changes are be- 
nign. The embryo in the first and second months may 
be absorbed, but at later periods, it becomes macerated 
petrified, or otherwise altered. 

Among the signs of foetal death are prolonged cessa- 
tion of foetal movements after being definitely observed, 
chilliness, languor and malaise of the mother, sense of 
weight in abdomen, and possibly a bad taste in the 
mouth. Furthermore, the uterus does not correspond to 
the period of pregnancy, and may have become smaller. 
Retrogressive changes take place in the breasts. 

The diagnosis is only certain when the heart tones 
are persistently absent, or the macerated head of the 
foetus is felt through the partly dilated os as a flabby 
bag of bones. 

Treatment in noninfective cases is expectant. Sponta- 
neous expulsion will occur sooner or later and there is 
no necessitous indication for interference. Local signs 
of putrefaction, however, make the immediate emptying 
of the uterus necessary. 



CHAPTER VII 



PREPARATIONS FOR LABOR AND THE NORMAL 
COURSE OF LABOR 

The Nurse.— Scientific obstetric nursing is a specialty 
that enlists the interest of exceptional women only. 

It demands a high sense of duty, a strong physique, 
broad training, unusual judgment, and rare tact. The 
nurse must be professionally aseptic and personally 
clean. She should keep herself free from odors, and 
bathe at least three times a week. The presence of pus 
anywhere on her body disqualifies her at once, and she 
should report off duty. 

The compensation should always be somewhat higher 
than for other work, because there are tAvo patients to 
be cared for. 

An obstetric nurse should specialize in her work, and 
not take infectious cases. Unhappily the haphazard 
character of the onset of labor presents a difficulty. 
The patient frequently can not afford to have the nurse 
for a long time in advance of labor, and the nurse whose 
income is limited by the number of her cases can not 
afford to be idle. Hence, it is better for two nurses to 
work in alternation with one another, so that one is al- 
Avays available in an emergency. 

Both doctor and nurse should visit the lying-in room 
before labor begins, and plan its rearrangement. At 
least a week before the expected confinement, the cham- 
ber selected should be thoroughly cleaned and the Avood- 
work AA r iped off. Curtains, draperies and bric-a-brac and 
all useless furniture should be removed. Carpets must 

98 



PREPARATIONS FOR LABOR 



99 



be taken up, or at time of confinement, well protected. 
Rugs can be easily managed. A chair, a bed, and the 
various tables for instruments and solutions are all that 
are required. 

The nurse usually is called to the case first, and upon 
her falls the responsibility of the diagnosis and the 
burden of the preparation. As soon as she arrives and 
satisfies herself that the patient is really in labor, she 
puts the final touches to the room. In her own mind 
she goes over all possible emergencies and prepares to 
meet them. 

The following supplies should be in the house for 
the labor: 

3 hand basins, 10 inches in diameter. 

3 hand brushes. 

1 two-quart douche bag. 
15 yards nonsterile gauze. 

2 lb. each of cotton batting and absorbent cotton for 

making bed pads. 
2 pieces of rubber sheeting 1 by 2 yards. 
5-yd. jar of borated gauze. 

4 oz. lysol (or ziratol). 

100 c.c. of Squibb 's chloroform. 
2 oz. green soap. 
2 oz. solid albolene. 
8 oz. alcohol. 
V2 oz. ergotol. 

V-> oz. bismuth subnitrate and % oz. boric acid powder 

mixed. 
1 nail file. 

Nurse's outfit consists of the following: Nail file, surgi- 
cal scissors, catheter (silver is best), hypodermic syringe 
with tablets of morphine, strychnine, and digitalis ; two 
fever thermometers, one for mouth and one for rectum ; 
a pair of tissue forceps and a razor. 

Some time, before the labor, the nurse should call on 
the patient and establish a working acquaintance. It 
adds greatly to her authority and to the patient's con- 



PREPARATIONS FOR LABOR 



101 



fidence in her. Her advice will be sought on a multitude 
of subjects, partly real and partly to try her out. 

Sterilizing may be done in a hospital, or, if this is not 
feasible, the nurse should go to the house two or three 
weeks before the expected labor and sterilize in an 
Arnold or Rochester sterilizer the following articles: 




Fig. 33. — Breast binder. 



Vi doz. sheets. 
3 doz. towels. 

2 pillow slips. 

3 abdominal binders of unbleached cotton, 16 in. wide and 

36 in. long, folded and hemmed. 

4 T bandages. 

3 breast binders. 

2 jacket parts of pajama suits. 

3 pairs of long white stockings. 

3 packages of vulvar dressings (see Preparation of Sup- 
plies, p. 326). 

2 obstetric pads 1 by 36 by 36 inches. 

1 pillow slip full of cotton pledgets for sponges. 

1 jar applicators (cotton twisted about toothpicks). 

1 jar of gauze pledgets for perineorrhaphy and cord dress- 
ings. 

Everything must, be neatly wrapped and labeled. 

Infant's Outfit. — 

12 plain slips 27 inches long of dimity or nainsook (with 
winged sleeves). 



102 



OBSTETRICS FOR NURSES 



3 long sleeve shirts, silk and wool (size No. 2). 
6 pinning blankets, made of outing flannel, if it is a win- 
ter baby. 

3 bands, 6 by 18 inches, clip or notch edges, do not hem. 
3 petticoats, flannel bottoms and muslin waists, without 

sleeves and with small button on shoulders. 
3 outing flannel wrappers. 
6 plain, soft muslin dresses. 
3 (Arnold) knitted night gowns, light weight. 



Fig. 34. — Baby's dress with winged sleeves. 

4 doz. light weight cotton diapers, 20x40 inches. Bird's- 
eye linen is the best. Wash and dry these in the 
air before using. 

4 soft towels (linen preferred). 

2 quilted pads. 

4 soft wash cloths. 

4 wool wrapping blankets. 

1 pair scales that weigh ounces and fractions thereof. 
4 oz. of olive oil or benzoated lard. 
4 oz. of alcohol (95 per cent). 
y± lb. boric acid crystals. 



PREPARATIONS FOR LABOR 



103 



y% lb. absorbent cotton. 

1 cake of castile soap. 

2 oz. solid albolene. 

% oz. subnitrate of bismuth powder and % oz. of pow- 
dered boric acid mixed. 

1 bed pan. 

2 basins, holding 2 quarts each. 

1 papier mache, rubber, or enamel ware bathtub. 

Ansesthetics. — Excessive pain is destructive and disin- 
tegrating to the vital forces. Many a woman who has 
passed through a particularly severe labor remembers 
her experience with a horror that forever precludes its 
repetition. 

This is the day of relative painlessness in labor, and all 
the world is striving to make childbirth easier and less 
lethal. Xo woman, unless she herself requests it, should 
be permitted to go through the agony of labor without 
an anaesthetic, judiciously selected and carefully ad- 
ministered. 

Pain-deadening agents are numerous and inexpensive, 
and it is only a matter of experience and judgment to 
choose a method that will reduce the suffering of child- 
birth to a minimum. The second and first stages of 
labor, in the order named, demand the most in the way 
of relief. 

A prolonged first stai>e with nailing;, violent and ap- 
parently useless pains may devitalize the patient more 
than short, but acute pains of the second stage. In the 
first stage, under proper selection of cases and expe- 
rienced supervision, " Twilight Sleep" will be success- 
ful in seventy to eighty per cent of the cases. 

By success, is meant that the patient is relatively free 
from pain. When the drugs do not relieve pain, the 
case is a failure (fifteen per cent), although in no case, 
when properly given, is the mother or child endangered. 
Morphine solution 1/6 gr. and scopolamine hydrobromid 



104 



OBSTETRICS FOR NURSES 



1/200 gr. to 1/150 gr. is the customary dosage for the 
first injection. Another injection of 1/200 gr. is given 
in a half or three-quarters of an hour. The room is 
darkened, talking is forbidden, and the family exiled. 
The patient gets red in the face and very thirsty, the 
pulse is rapid but full. She answers questions very 
slowly and drowsily, awakes for her contraction but 
goes right off to sleep again. In this condition she is 
kept through bi-hourly repetitions of the scopolamine 
until the delivery. It is this half waking and half sleep- 
ing condition that suggested the name of "Twilight 
Sleep." 

Morphine and scopolamine will relieve the pains of 
the first stage without greatly protracting the labor. 
The same drugs may and probably will prolong the 
duration of the second stage. The first dose should be 
given as soon as the patient is well started in labor. 

"Twilight Sleep" is at present a hospital procedure, 
and the technic so exacting as to weary the attendants 
greatly. It can not be employed until the woman has 
definitely gone into labor and is at least three hours 
aAvay from delivery. It is not serviceable where the 
pains are weak and shallow ; and it must be used with 
wise circumspection, if at all, in the presence of compli- 
cations. 

For the second stage, there is a choice of three drugs: 
gas, chloroform, and ether. Like twilight sleep each is 
open to some objection, but each may be of the greatest 
assistance if used under appropriate indications and con- 
ditions. 

Gas has one advantage, in that it in no way interferes 
with the pain activities ; and Lynch and Davis have shown 
that with a proper admixture of oxygen, it may be 
given with comparative safety for the two or three hours 



NORMAL COURSE OF LABOR 



105 



which may mark a normal second stage. To administer 
it a competent machine for mixing the gas is necessary. 
It should not be given to patients who have bad hearts, 
high blood pressure, or toxa?mia. Neither is it a satis- 
factory anaesthetic when the head delivers, for the mother 
being less relaxed and more rigid, the legs and muscle 
action are harder to control and unnecessary perineal 
lacerations are liable to occur. Tbe patient is instructed 
to take several deep breaths just as the uterine contrac- 
tion comes on and the gas bags supply about 75 per cent 
nitrous oxide and 25 per cent oxygen. As the pain passes 
off tbe oxj-gen is increased and the nitrous oxide dimin- 
ished until the mind is again clear. 

To save the perineum and better to control the patient, 
when the head is about to pass the vulva, it is wiser to 
abandon the gas for chloroform or ether. 

Obstetrical operations, such as forceps and version, 
require ether or chloroform, and not gas. The dangers 
vary with the anaesthetic chosen, as well as the amount 
and the method of administration. Ether affects the 
respiration, chloroform attacks the heart. Ether must 
not be given near an open flame. Chloroform is not 
explosive but is decomposed by fire into an irritating 
gas. Chloroform must be diluted with 90 per cent of 
air, hence the mask must be open, or the napkin held 
free from the face, so that plenty of air can enter. Ether 
and chloroform, when given "a la reine;" i. e., a few 
drops on the mask at the beginning of each pain and 
increased up to the acme, is relatively free from danger. 
They have the additional advantage that the sleep may 
be instantly deepened if operation is required. Chloro- 
form, it is iioav believed, predisposes mildly to post 
partum haemorrhage. Davis has shown that neither 
ether, gas, nor chloroform affects the child injuriously if 



106 



OBSTETRICS FOR NURSES 



the administration is intermittent and not too greatly 
prolonged. 

To summarize: Morphine and scopolamine combined 
is a first stage analgesic, which has too much value to be 
neglected. 

Gas, if an apparatus is to be had, may work well for 
the greater part of the second stage, while for opera- 
tions, or for the period of expulsion, during which the 
head passes the perineum, chloroform and ether give 
bests results. Moreover, chloroform ''a la reine" may 
be given safely and efficiently by a competent nurse 
and in many instances must be given by the nurse, if at 
all. 

When the perineum bulges, or the head becomes vis- 
ible at the vulva, the nurse should anoint the lips, cheeks 
and tip of the nose with cold cream or olive oil, to avoid 
burning the skin, and lay two or three thicknesses of 
handkerchief or gauze over the nose (an inhaler is best). 
An abundance of room must be left underneath and at 
the sides of the mask for air to enter. 

At the beginning of the pain a few drops of chloro- 
form are poured on the cloth and the patient instructed 
to breathe vigorously. The cloth is removed as soon 
as the pain ceases and when the next contraction comes 
on, the process is repeated. As the head passes the 
perineum, the chloroform should be pushed to complete 
anaesthesia, both to save suffering and to give the doctor 
full control of the perineum. When the nurse gives the 
anaesthetic, she should watch the doctor for his signal to 
increase the vapor or remove the mask. 

Summary. — Cover the eyes with a wet towel and anoint 
the face with cream or oil before using chloroform. Re- 
move false teeth, if present. 

Obstetric degree — a few drops on mask at beginning 
of each pain. 



NORMAL COURSE OF LABOR 



107 



Surgical degree — complete anaesthesia. 
Watch pulse and respiration. 

A nurse should never leave a patient who has had an 
anaesthetic until she is conscious. Vomiting is especially 
dangerous. 

Normal Labor. — Labor is the process by which a 
foetus of viable age is expelled from the uterus. 

By normal labor is meant a case where the foetus pre- 
sents by the vertex and terminates naturally without 
artificial aid, or complications. It varies greatly in se- 
verity, duration and danger to mother and child. A first 
labor is more prolonged and difficult than later confine- 
ments. A woman in her first delivery is called a primi- 
para, in subsequent cases, a multipara. 

The date at which labor comes on is difficult to deter- 
mine accurately. The average duration of pregnancy is 
from 275 to 280 days, forty weeks, or ten lunar months, 
but conception does not occur necessarily at the time of 
coitus, nor is it possible to know with any certainty 
when it does occur. 

Labor may occur two weeks earlier than calculated, 
with benefit to the mother, and no harm to the child ; 
but if the woman goes over time, the child becomes much 
larger and the labor harder and more dangerous to 
both. 

Causes of Labor. — Why labor should occur at all is not 
known. Many theories have been advanced, none of 
Avhich is entirely satisfactory. Some of the best known 
are the growing irritability of the uterus accompanied 
by an increase in the frequency and strength of the in- 
termittent uterine contractions or increasing distention 
of the uterus. Thus it is believed that when the uterus is 
distended up to a certain point, it will try to relieve 
itself like the bladder, or a baby's stomach. It may be 



108 



OBSTETRICS FOR NURSES 



that any one of the following factors, or all of them 
acting together, are influential. 

Dilatation of the cervix by the presenting part. 

Increasing distention of the lower half of the uterus 
with pressure on neighboring nerve structures. 

The circulation of foetal products of metabolism 
(toxins) acting on the nerve centers. 

The menstrual periodicity. 

Heredity and habit. 

Physical and emotional causes. 

The onset of labor probably is not purely accidental, 
and yet it is so inconstant in appearance and so indiffer- 
ently early or late, that it has every appearance of being 
an affair of chance. The time when labor will come on 
is highly speculative in general, but the phenomenon is 
preceded by certain definite symptoms: 

The lightening. 

False pains. 

Show. 

Rupture of membranes. 
The pains. 

Lightening. — About two weeks before labor, especially 
in a primipara, the uterus and the head sometimes descend 
into the pelvis. The body of the child falls forward and 
the abdomen protrudes, the stomach is flatter, the pa- 
tient breathes easier and feels, as she says, "lighter." 
But walking is more difficult, the bladder is stimulated 
to frequent evacuations and the rectum is compressed. 

This occurrence is a premonitory sign of labor, and 
also favorable inasmuch as it demonstrates that this 
particular head is not too large to pass this particular 
pelvis. 

False pains may appear, especially in multiparas, from 
two to four weeks before labor. In some of these cases 



NORMAL COURSE OF LABOR 



109 



the pains may be due to gas or indigestion and respond 
to hot applications and enemas, or there may be definite 
uterine contractions, as shown by the hardness of that 
organ during a pain, but the phenomena are irregular 
and therefore not typical of labor pains. 

Usually they pass off in a few hours, but if the patient 
is nervous, the doctor or nurse may be called needlessly. 
The patient, therefore, should be instructed to have the 
pains timed by the watch for half an hour or an hour. 
If they are regular during this period, the physician 
should be notified. Upon his arrival, an internal exam- 
ination will reveal the true character of the disturbance 
by the condition of the cervix and os. 

The show is a discharge of thick, white mucus, slightly 
stained with blood. This is the mucus plug which occludes 
the cervix during pregnancy and when the os begins to di- 
late, the mass is released and passes out. Labor usually 
comes on vigorously within twelve hours. 

Th e membranes may rupture before labor begins and 
much fluid escape. The advantage of the dilating bag 
of water and lubricating qualities of the liquor amnii 
are thus lost. Such a labor is called a "dry-birth" and 
is frequently slow, exhausting, and extremely painful. 

The pains are the subjective manifestations of the 
powers of labor. The forces concerned are uterine and 
abdominal muscles, principally assisted by those of the 
back, legs, and arms. Their constricting action on the 
nerve fibers in the walls of the uterus is the cause of 
the pains in the first stage, The onset may be violent 
and go on to a quick delivery, but generally the incep- 
tion is more insidious. 

The irregular, painless contractions, (of Braxton Hicks) 
that were mentioned on an earlier page, gradually at term 
change their character and become regular and painful. 



110 



OBSTETRICS FOR NURSES 



At first they may be slight and vague, lasting only half 
a minute and separated by intervals of ten or fifteen 
minutes and scarcely attract the patient's attention. 
They are felt chiefly in the abdomen. 

More or less rapidly they increase in frequency, sever- 
ity and duration. They last from a minute to a minute 
and a half and come every three minutes. The whole 
uterus hardens and its outline is clearly defined during 
the contraction ; it relaxes and becomes soft in the in- 
terval. The woman is now in labor. The pains become 
grinding and the patient feels that she is not accom- 
plishing anything, yet under the influence of these con- 
tractions the cervix is effaced and the os is dilated. 

The Course of Labor. — Labor is divided for conven- 
ience into three stages as follows: 

The first stage, from the beginning of pains until the 
complete dilatation of the os. 

The second stage, from the complete dilatation of the 
os to the delivery of the child. 

The third stage, from the delivery of the child to the 
expulsion of the placenta. 

The first stage is the stage of dilatation. 

Usually at term, the cervix is columnar and unshort- 
ened, the canal intact, and closed at both ends, as shown 
in Fig. 36. 

In multiparas the outer opening will usually admit 
the tip of the finger. 

As labor proceeds, the cervix is effaced, the os slowly 
dilates, and the bag of waters forms. 

The Bag of Waters. — When the cervix is effaced and 
only the os remains, the lower end of the egg with its 
fluid restrained by the membranes, bulges forward into 
the canal. The foetal head, or breech presses into the 
pelvis, and the fluid in the membranes, compressed be- 



NORMAL COURSE OP LABOR 



111 



tweeii the presenting part above and the cervix below, 
is called the bag of waters. 

When the contraction comes on the longitudinal muscu- 
lar fibers of the uterus arc drawn upward and the bag of 
waters becomes tense and pushes farther and farther 
down into the opening; and by its even and universal 
pressure, mechanically and slowly increases the size of 
the opening which the muscular traction is pulling apart. 
At the same time, the fluid around the child prevents, for 




Vagina 



Fig. 35. — The bag of waters begins to act on the cervix. (Fden.) 

a time, direct and injurious compression on the body. 
When no definite cervical projection can be felt, and 
when the teat-like protrusion of the cervix has disap- 
peared, the cervix is said to be effaced. 

The os now begins to stretch and widen, the bag of 
waters becomes more and more evident, vomiting occurs, 
and at last, when the os has expanded to a diameter of 
four inches (ten centimeters), the membrane can with- 
stand the pressure no longer. It ruptures, a certain 
amount of fluid escapes, the presenting part conies down 




Fig. 37. — The effect of the pains. The cervix begins to be "effaced. " 
(Bnmm.) 



NORMAL COURSE OF LABOR 



113 




114 



OBSTETRICS FOR NURSES 



against the opening, and like a valve, prevents the out- 
flow of the waters from above. 

Sometimes the labor may be preceded by some hours 
(two or three), or days (two or three), even weeks 
(two or three), by the rupture of the membrane, and 
sometimes when the structure is thick and tough, the 
rupture may be delayed until well into the second stage, 
or even until the child is born. In the latter case, the 
head comes out, covered with membrane. In the old 
days, this was called being "born with a caul." It was 
supposed to be a lucky omen, but it was lucky only that 
the babe escaped suffocation. The membrane should be 
torn open quickly. 

The duration of this stage is variable. It is much 
longer in primiparas than multiparas. It averages six- 
teen hours in the former, and eight hours in the latter. 
Vomiting during this stage is quite common, but the 
pulse and temperature remain normal. The first stage of 
labor is usually under the entire control of the nurse. It 
is her responsibility. 

With complete dilatation of the os, the second stage, or 
stage of expulsion, begins, whether the membranes rup- 
ture or not. The presenting part, usually the head, 
passes from the cervix into the vagina. The vagina in 
turn gradually dilates from above downward until 
uterus, cervix and vagina form a single, Made channel of 
the same diameter. The child is driven forward by the 
uterine contractions, strongly reinforced by the abdom- 
inal muscles, which the patient uses vigorously. The 
onset of each pain is accompanied by a deep inspiration, 
followed by straining or bearing down with the abdom- 
inal muscles as in a highly exaggerated bowel move- 
ment. The patient holds her breath, braces her feet, 
fastens her hands on bed or attendant, and uses all the 
trunk muscles in the effort. The face becomes con- 



NORMAL COURSE OF LABOR 



115 



gested, the pulse quickened, she perspires some, and 
groans deeply during the contraction. The pain is ex- 
treme and is due partly to the stretching of the vagina 
and vulva and partly to the distention of deeper sensi- 
tive structures. 

When the head reaches the pelvic floor, the first 




Fig. 40. — The cervix is effaced, and the os dilated. The second stage begins. 

(Eden.) 



change observed in the external genitals is the stretch- 
ing (bulging) of the perineal body. Next, the anus be- 
comes turgid, dilates slightly, the anterior wall becomes 
visible, and the hairy scalp of the child appears at the 
vulva. The actual expulsion of the head in a primipara is 
accomplished by a series of prolonged and severe contrac- 
tions, accompanied by violent straining. 



116 



OBSTETRICS FOR NURSES 




Fig. 41. — Child in second stage of labor with bag of waters unruptured and 
presenting at the vulva. (Braune, from Harbour.) 

A short pause ensues, followed in two or three min- 
utes by a return of the pains, which expel first the 
shoulders and then the trunk. As the body escapes it 
is followed by a rush of blood-stained liquor amnii. 
This is the fluid that has been pent up in the uterus by 



NORMAL COURSE OF LABOR 



117 



the obstructing body of the child. The second stage 
lasts about two hours in a primipara and from fifteen 
minutes to one hour in a multipara. 

The third stage is the delivery of the after-birth. The 




Fig. 42. — The head rassing over the perineum. (Bumtn.) 



after-birth sometimes called the secundines, consists of 
placenta, umbilical cord, and membranes. 

After the expulsion of the foetus, the uterus undergoes 
a sudden diminution in size. It is about as large as the 
child's head, and the fundus lies near the level of the 
umbilicus. The contractions still persist feebly, but they 
are practically painless, and the patient is greatly re- 
lieved, possibly sleeping. 



118 



OBSTETRICS FOR NURSES 



In from ten to thirty minutes, the uterus becomes 
smaller, harder, more globular in shape and more mov- 
able. The patient brings the voluntary muscles of the 
abdomen strongly into action again. The nurse presents 
a sterile basin and the physician sustains and slowly 
twists the membranes free from their final attachment 
and out of the uterus. When the placenta passes the 
vulva, a moderate sized blood clot follows it. 




Fig. 43. — Normal expulsion of the placenta like an inverted umbrella accord- 
ing to Schultze. (Williams.) 



The uterus is now much smaller, and hard and firm 
in consistency, but for some hours the contractions are 
intermittent, and while this continues, there is risk of 
haemorrhage. 

General Effects. — The mother's pulse is quickened dur- 
ing the contraction. The foetal heart beats more slowly 
and feebl}* during a contraction, but quickly recovers in 
the interval. 



NORMAL COURSE OF LABOR 



119 



The amount of blood lost during labor averages from 
ten to sixteen ounces. The temperature may be elevated 
one or two degrees in a woman of moderate physique, 
while one with a fragile body may present the signs and 
symptoms of surgical shock. The chill, pallor, cold 
limbs and body, rapid and feeble pulse with subnormal 
temperature, suggest to the nurse at once the proper 
treatment. Heat, to all parts of the body, warm covers 
and hot milk or coffee. If hemorrhage is present and the 
uterus relaxed, the nurse should immediately inject pit- 
uitrin (15 Tti ) into the deltoid muscle and notify her at- 
tending physician. 



CHAPTER VIII 



THE MECHANISM OF NORMAL LABOR 

The powers of labor are primarily the uterine con- 
tractions strongly aided by the muscles of the abdomen 
and diaphragm. Some assistance is given by the fixa- 
tion of the legs and arms and sometimes by gravity, 
when a sitting or standing position is maintained. 

The resistances are the bony pelvis and its relatively 
soft coverings of muscle and fascia. 

The problem is to get the awkwardly shaped passen- 
ger through the curiously shaped passage. 

In the first, and a part of the second stage, the uter-. 
ine contractions do not act directly upon the body of 
the child, for the latter is surrounded by a wall of liquor 
amnii. 

Pressure is transmitted by a fluid medium in all direc- 
tions, hence, the weak part of the Avail, which is the 
cervix, must give way. While the membranes remain in- 
tact, or when sufficient fluid is retained, no amount of 
pressure can injure the foetus. When the membranes 
rupture, the force of the pains is exerted directly upon 
the child to drive it forward, and prolonged pressure 
may produce injurious effects through compression of 
foetus, placenta, or cord. 

The progress of labor is registered usually by watch- 
ing the advance of the foetal head. 

The relation of the head to the pelvic brim is of 
great importance, as it travels much faster and easier 
in certain positions than in others. The term "presenta- 

120 



MECHANISM OF NORMAL LABOR 



121 



tion" is used to designate that part of the child which 
enters or tends to enter the pelvic inlet. 

The presentation is named from the part of the child 
which conies into apposition with the brim. Thus, one 
speaks of a vertex presentation, or a breech presentation, 
or a shoulder presentation. The presentation is de- 
termined externally by palpation. 

The vertex presents in 9b' per cent of all labors. With 
the vertex presenting, the head may occupy any one of 
four positions. The term "position" is used to explain 
the relation which the most distinctive feature of the 
presenting part bears to the quadrants of the pelvic in- 
let. Thus, the most distinctive feature or landmark of 
the vertex is the occiput, which is the point of direction, 
and so again, the position is the relation of the point of 
direction to the brim of the pelvis. The point of direction 
is the part that takes precedence in the process of de- 
livery. Thus, in all cases where the occiput is in advance, 
the occiput is the point of direction and the position is 
called occipital. Where the chin is in advance, it is men- 
tal (mention is Latin for chin.) In breech cases, the 
sacrum is the point of direction. 

The pelvis is divided by the transverse and anteropos- 
terior diameters into four quadrants named respectively 
the left anterior, the right anterior, and the right and 
left posterior. (See Fig. 1.) Thus, in a vertex presen- 
tation the back of the child may be (and in 53 per cent is) 
to the front and to the left, 

The occiput is the point of direction, and lies in rela- 
tion to the left anterior quadrant of the pelvis, and is 
spoken of as a left-occipito-anterior position. Similarly 
a right-occipito-anterior position is named, and right and 
left occipito-posterior positions. These occur respec- 
tively in about 21 per cent, 14 per cent and 11 per cent 
of the cases. (Eden.) 



]22 OBSTETRICS FOR NURSES 

In passing the pelvis, the foetus not only follows the 
curved line of the pelvic axis, but it describes a cer- 
tain series of movements which alter its relations to the 
pelvis. 




pig. 44. — 'fhe child in left-occipito anterior position. (Lenoir and Tarnier.) 



There are five of these movements: flexion, descent, 
internal anterior rotation, extension, and external resti- 
tution. 



MECHANISM OF NORMAL LABOR 



123 



Flexion. — Flexion is usually present before labor be- 
gins. That is, the head is bent down until the chin 
touches the breast. This may be modified by various 
conditions, but so far as it becomes extended, the mech- 
anism is disturbed and the labor complicated, since 
large and less favorable diameters are brought to de- 
livery. 




Fig. 45. — The child in right-occipito anterior position. Shows the flexion of 
the head intensified at the beginning of labor. (Eden.) 

Flexion is increased by pressure against the pelvic 
brim as labor begins. 

Descent. — As the driving force of the contractions 
becomes effective, the head passes the inlet and descends 
to the pelvic floor. When the large diameters of the 
head (biparictal) have passed the inlet, the head is said 
to be engaged. 



124 



OBSTETRICS FOR NURSES 



Internal Rotation. — The head most frequently enters 
the brim with the occiput to the left and anterior 
(obliquely) because it finds more room and an easier 




a b 



Fig. 46 A. — The descent of the head in right-occipito-anterior position. 
Seen from below. (Edgar.) Fig. 46 B. — Side view. 




Fig. 47. — Internal anterior rotation and extension of the head in a left- 
occipitoanterior position. (American Text Book.) 

passage; but upon passing this strait and entering the 
roomy, true pelvis, the head must rotate so that the long 
diameter of the head will conform to the long di- 



MECHANISM OF NORMAL LABOR 



125 




I i;?. 4&. — Extension. A, die chin haves the ch~st; D, extension in progress. 




Fig. 49. — A, extension completed; B, expulsion. (Eden.) 



ameter of the pelvic outlet, which lies in a direction 
just opposite to the long diameter of the inlet or brim; 



126 



OBSTETRICS FOR NURSES 



hence, the occiput turns forward under the pubic arch. 
This movement is due largely to the sloping pelvic floor 
and the necessity of accommodation between the head 
and pelvis as the child is driven forward. 

Rotation is much retarded or entirely stopped when 
the head is extended instead of flexed or when it enters 
the inlet with the occiput posterior instead of anterior. 

Extension.— After internal, anterior rotation, the head 
emerges at the vulva, the occiput coming out first, then 
in succession the vertex, forehead and face and chin. 
As the chin rolls out over the perineum, it moves away 
from the chest wall — it becomes extended. 

External Restitution.— While the head is passing 
through the outlet, the shoulders are entering the pel- 
vic inlet, and so soon as the head is released from the 
restraint of the vagina, it naturally falls into its normal 
relation to the foetal back; hence in the position now dis- 
cussed, it turns toward the left. 

Therefore, we may summarize the mechanism in a 
normal left-occipito-anterior position of the head by 
saying: The head is flexed and forced into the pelvis. 
It descends to the pelvic floor. The occiput rotates to 
the front of the pelvis and impinges against the sym- 
physis. Extension ensues in consequence of the neces- 
sity for an accommodation between the pelvis and the 
advancing head, and during this extension, the head de- 
livers over the perineum. External restitution follows. 

The Effect of Labor on the Fcetal Head. — As the head 
passes through the canal, it is -moulded by contact with 
the resistances. The degree of moulding is proportion- 
ate to the pressure required to drive it through. Thus, 
in a large head, or a relatively small pelvis, the mould- 
ing may be extreme, and changes in the scalp are com- 
mon. 



MECHANISM OF NORMAL LABOR 127 

Caput Succedaneum. — Since all parts of the scalp are 
in contact with a resistant Avail, except in the center of 
the birth canal, an effusion of serum takes place here, 




Fig. SO. — A cephalh.-ematomata. Do not confuse with caput succedaneum. 

(Bumm.) 

which is due to the obstruction of the venous circula- 
tion. 

Swelling occurs in the subcutaneous cellular tissue, 
and a tumor forms — the caput succedaneum — which 
spontaneously disappears in twenty-four or forty-eight 



128 



OBSTETRICS FOR NURSES 



hours. It is useful in confirming the diagnosis of the 
position. 

Cephalhematoma. — Following labor a tumor is some- 
times found upon the head, which is often confused with 
a caput succedaneum. 

This tumor is caused by an effusion of blood beneath 
the periosteum or the covering of the bone — usually a 
parietal bone. It is sometimes single and sometimes 
double, and it varies in size from a filbert to a peach. 
The swelling never extends across a suture. The effu- 
sion takes place gradually, and may not appear for a 
day or so after birth. The cause is unknown, for it oc- 
curs after normal and easy, as well as after difficult, 
deliveries, and after breech, as well as vertex, cases. 

At first it fluctuates, then becomes hard, and in a 
few weeks or months is gradually absorbed. If symp- 
toms of cerebral pressure develop, it must be remem- 
bered that haematoma may occur inside as well as out- 
side the cranium. 

No treatment is necessary. Puncture is inadvisable. 
In extremely rare instances the tumor may suppurate 
and require incision. 



CHAPTER IX 



THE CARE OF THE PATIENT DURING NORMAL 

LABOR 

Every case of labor must be conducted with the most 
scrupulous attention to surgical cleanliness on the part 
of the patient, doctor and nurse. Puerperal infection 
in most cases is due to the introduction of disease-pro- 
ducing microbes into the wounded genital canal. To be 
sure, the successful enforcement of surgical cleanliness 
is attained only in good hospitals, but it can be approxi- 
mated in a private house if the patient insists upon de- 
livery at home. 

A nurse or doctor who is clean of person, is most 
apt to have an "aseptic conscience." The possession 
of such a conscience may entail financial sacrifices, but 
it has many compensations. Neither the nurse nor the 
doctor is doing justice to the patient, nor to the profes- 
sion, who indiscriminately takes pus cases, contagious 
diseases, and confinements. The public will soon learn 
that such a nurse and such a doctor are unsafe attend- 
ants. 

How may the nurse know that the patient is in labor ? 
This is the final assumption that must be confirmed or 
refuted when the nurse is called to her case. It is 
ascertained partly by the history and partly by the 
conditions found. 

Thus, the patient may report the passage of a piece 
of blood-stained mucus, and the nurse will observe 
that the contractions of the uterus are regular, rhyth- 

129 



130 



OBSTETRICS FOR NURSES 



mical and painful. She will observe that when the pa- 
tient complains of pain, the uterus gets hard. She will 
also observe the definite regularity of the contractions 
by timing them. 

Under such conditions, the doctor should be called 
at once if the symptoms develop between 7 a. m. and 




11 p. m. If the pains begin in the night, say from 11 
a. m. to 7 p. m., the doctor need not be called unless he 
has requested it, or, unless in the judgment of the nurse 
or the anxiety of the patient, it is desirable for him to 
see her. 



CARE OF PATIENT DURING LABOR 



131 



When the doctor is notified he will want to know, and 
the well trained nurse will be able to inform him, when 
the pains began, their strength, duration and frequency. 
He will want to know whether or not the membranes 
have ruptured. Many doctors also require, and a well 
trained nurse who specializes in obstetrics should be 
able to say by external examination, whether the head 
seems high or low, as well as the position and frequency 
of the foetal heart tones. 

In the hospital the following rules for summoning 
the resident physician may be found useful: 

1. For multipara, when pains arc regular and five minutes 
apart. 

2. For primipara, when pains are regular and two minutes 
apart, or when head is visible if pains are less frequent. 

3. If a precipitate is imminent, delivery must, be delayed 
until arrival of attending man by — 

(a) Turning patient on side with legs straight; 

(b) Instructing patient to breathe deeply or to cry out 
with mouth wide open; then 

(c) Place sterile towel over vulva, and at time of pain 
prevent expulsion by compressing the head by 
means of locking the hands over a towel on the vulva. 

It is possible thus to delay delivery two hours, or 
until the doctor arrives. Do not permit a precipitate. 

After the nurse has completed her preliminary ob- 
servation, she starts her history, notes the character 
of the pains, the pulse, temperature and respiration. All 
unusual phenomena should be recorded; and after the 
visit of her attending man, his examination, if any, and 
the conditions found, are put down. Then she prepares 
the patient and sets up the room for the delivery. 

Preparation. — As soon as the patient is known to be 
in labor, the bowels are thoroughly cleansed with a soap- 
suds enema. A toilet jar should be used and not the 



132 



OBSTETRICS FOR NURSES 



water closet. The bladder must be emptied at the time 
of preparation and at frequent intervals throughout the 
labor. As soon as the bowels and bladder are emptied, 
the patient is given a bath and thoroughly soaped. The 
shower is preferred lest the water, contaminated by 
bacteria from the skin and external genitals, should en- 
ter and pollute the vagina. 




Fig. 52. — Handling forceps, kept sterile in a jar of alcohol. 

The hair should be braided in two braids. The vulva 
and perineum are shaved. No patient will object to this 
when its importance as a feature of protection against 
blood poisoning is explained to her. 

Scrub thighs, hips, and abdomen as far as the navel 
with soap and warm water, then sterile water, followed 



CARE OF PATIENT DURING LABOR 



133 



by a 2 per cent solution of lysol. Care must be taken 
to remove the smegma and dried secretions from the folds 
of the vulva. Put on a fresh pad, a clean gown, and 
long stockings. A loose wrapper over all permits the 
patient to move about. (See Chapter XXIII.) 

Guests are forbidden, and the immediate family is 
kept at a distance — if possible. 

An air of buoyancy, composure, and competence 
should prevail in the sick room, and the patient should 
be cheered and encouraged in every possible way. 

During the first stage, the patient may be up and 
about, as this diverts the mind. She may assist in the 
arrangement of the room which should always be the 
best room in the house. It should be well warmed and 
close to the bathroom. All unnecessary furniture and 
hangings should be removed, as previously described. 
After the room has been put in order, the bed is made. 

Making' the Bed. — Put mattress pad over mattress and 
cover with rubber sheet or oil cloth, and spread a sheet 
over all. Then a smaller rubber sheet is put on, ex- 
tending from under the pillows to a couple of feet from 
the foot. A plain muslin sheet goes over the rubber, 
then the delivery pad. 

AVhen the bed is ready, a small table or stand should 
be placed near the head, on which is put the anaesthetic, 
the mask and the oil or cold cream. The patient may be 
lightly covered with a sheet or a sheet and blanket. 

During the first stage, light and easily digested food 
and drinks may be served, either cold or hot, as the pa- 
tient prefers. 

AVhen the doctor arrives he may want to examine the 
patient either externally or internally, or both. So a 
sheet is thrown across the lower part of the body and 
the night-dress pulled up as far as the breasts. 



134 



OBSTETRICS FOR NURSES 



For the external examination the doctor washes his 
hands in warm water and green soap and scrubs with 
the nail brush for five minutes. This period should be 
prolonged to fifteen minutes, if, by any mischance, the 
hands have been in contact Avith pus or infectious ma- 
terial. It is extremely difficult to get them even ap- 
proximately clean after such an experience. 




Fig. S3. — Palpation. What is in the pelvis? (Eden.) 

He now palpates the abdomen, notes the location of 
the head and back, finds and counts the heart tones, 
measures the pelvis and child, estimates the descent of 
the head and the character of the pains. 

If he thinks an internal examination is necessary, he 
will now return to the bathroom, pare and clean his 
nails, scrub hands and arms to elbows for ten minutes 



CARE OF PATIENT DURING LABOR 



135 



in running water with green soap and a sterile brush, 
soak the hands in lysol solution 0.5 per cent for five min- 
utes. Bichloride of mercury solutions have no place in 
obstetrics. They ruin instruments and hands, and are 
valueless for asepsis since the mercury unites with the 
albumin of the mucoid discharges and forms an al- 
buminate of mercury, which is inert. The bichloride 




Fig. 54. — Palpation. What is in the fundus? (Eden.) 

solutions also are nonlubricating, harsh and astringent, 
as well as poisonous, as soon as the mucoid protection 
has been removed. When the doctor takes his hands from 
the lysol solution, they should be wiped on a sterile towel. 
A sterile gown is put on, if possible. If it is not avail- 
able, he should be careful not to touch anything that 
may destroy or contaminate his preparation. The hands 



136 



OBSTETRICS FOR NURSES 



are powdered and sterile rubber gloves pulled on (one 
will do.). 

The nurse, meanwhile, has wrapped the legs of the 
patient in the ends of a sterile sheet, the bulk of which 
covers the abdomen. The knees are spread apart. The 




Fig. SS. — Palpation. Where is the hack? Where are the small parts? (Eden.) 

vulva cleansed Avith pledgets of cotton soaked in lysol 
solution. One or two pledgets are used on either side 
of the vulva and the same number for cleansing the in- 
troitus. 

The fingers are now introduced. 

The internal examination may be conveniently post- 
poned until the waters break, or it may be omitted alto- 



CARE OF PATIENT DURING LABOR 



137 



gether if the heart tones of the child remain good, the 
labor progressive, and the head continually advances 
into the pelvis, as determined by the external examina- 
tion. The great advantage of an internal examination 
at this time is the diagnosis of the degree of dilatation 
and the assurance that the cord has not been washed 
down into the vagina by the rush of fluid. 

If the first stage is prolonged, the nurse should try to 




Fig. 56. — Patient draped for internal examination. (Williams.) 



get the patient to rest, and she should herself snatch a 
few moments of repose if possible. 

The condition of the os and the character of the pains 
may make the doctor feel safe in leaving the house, 
but his whereabouts and telephone number should be 
ascertained and the exact time of his return. 

Second Stage. — During this stage, the patient should 
go to bed and the doctor should remain nearby. The 



138 



OBSTETRICS FOR NURSES 



nurse may observe the vulva at intervals and note bulg- 
ing, if present, or she may press a finger against the soft 
parts outside the labia and see if the hard resistant head 
has come into the outlet. 

The pains are severe and all accessory muscles are 
called into action. Partial anaesthesia should be main- 
tained in most cases, which should merge into complete 
narcosis as the head passes the vulva. The nurse may 
have to administer this. 

When this stage begins, or is well under way, the 
patient should be prepared. A sterile pad should be 
placed under her, then a sterile bed pan. The nurse 
having prepared her hands and arms as previously di- 
rected for the doctor, scrubs abdomen, legs, and vulva 
with green soap and warm water, followed by lysol so- 
lution 0.5 per cent and a rinsing with sterile water. 
The cleansing of the patient should take about ten min- 
utes. Cover with a sterile towel and put on the sterile 
linen. 

If in the hospital, the drums have been packed for 
sterilization so that when they are opened each article 
will appear in the order of its need: 

No. 1. (Beginning at the bottom.) A receiving blanket, 
which has a ticket, marked with the weight of the blank- 
et, attached to it. 

1 abdominal binder with pad holder attached. 

1 pillow slip folded half way back. 

1 gown for patient. 

2 surgeon's gowns. 

3 sheets. 

1 pair surgical stockings folded half way. 
1 surgeon's gown for nurse. 
No. 2 contains cotton pledgets. 

No. 3 contains strips of gauze and combination pads. 

Application of Sterile Linen — Normal Case. — Sterile 
linen is to be applied as follows, by a clean nurse: 



CARE OF PATIENT DURING LABOR 



139 



1. Lay sheet across foot of bed and half way up. 

2. Put surgical stocking on one foot and draw sheet up for 
foot to rest upon. 

3. Second foot as above. 

4. Lay sterile sheet across bed under patient, letting ends 
hang. 

5. Lay sterile sheet over abdomen of patient. 

In many hospitals the sterile stockings and protective 
sheet are all made in one piece, which greatly simplifies 
the application of the linen. 

As soon as the second stage begins, the packet con- 
taining the perineorrhaphy and cord set, carefully ster- 
ilized, is brought out and placed in convenient reach of 
the doctor. 

This set contains — 

8 in. forceps. 

2 scissors curved on the flat. 

1 dissecting forceps. 

1 duck bill speculum. 

1 needle holder. 

1 metal catheter. 

8 gauze sponges. 

1 medicine dropper. 

1 cord clamp, or 

2 cord tapes. 

2 case numbers, attached. 

12 needles, 4 round, 4 half curved cervix needles, and 4 
skin needles. 

This is the stage of expulsion and the patient may 
want to pull or push on something to aid the straining 
effort. Unless the nurse needs time to set up the room 
or to get the docor, this tendency may be encouraged. 

A sterile sheet may be attached to the foot of the bed 
and the ends (corners) given into the patient's hands 
as a knot or loop to pull on, or she may push upward 
against the head of the bed. Under no circumstances 
must she be permitted to touch or contaminate the clean 



140 



OBSTETRICS FOR NURSES 



linen in her movements, either consciously or uncon- 
sciously. The hands should be restrained, if necessary, 
to avoid this. 

The face may be sponged and a cold towel laid across 
the eyes. Rubbing of the back and legs will bring great 
comfort, and cramps of the limbs may be removed by 
straightening the legs and rubbing the muscles under- 
neath. Everything is now ready for the delivery. If 
the husband insists upon being in the room, he should 
take off his coat and vest and wear a gown, or if the 
labor is in the home, drop a clean night robe over his 
clothes. 

The prepared room will show at close hand-reach, the 
basins of solutions, the pledgets of cotton, tape or clamp 
for cord, scissors, nitrate of silver solution (1 per cent) 
for the eyes, with dropper, the sterile douche can in 
readiness for hsemorrhage and a large reserve of sup- 
plies. Whatever anaesthetic has been chosen for the 
second stage, is now administered. Throughout this 
stage, the heart tones of the child must be watched, as 
well as those of the mother, for intra-partum death 
may occur at any moment. 

A second examination may be desirable now to con- 
firm the diagnosis and to secure an estimate of the 
advance. As a rule, the examinations should be as few 
as possible on account of the danger of infection. 

This is the period of greatest responsibility for the 
doctor whose duty it is to watch and, if necessary, to 
restrain the advance of the head in order to protect 
the perineum from rupture. 

This may be done at times most successfully, or in the 
case of too few assistants, most desirably, by delivery 
on the side. To secure this, as the head becomes more 
and more visible, the woman is turned upon her left 



CARE OF PATIENT DURING LABOR 



141 



side; a pillow rolled tightly and pinned in a sterile 
covering is placed between the knees, and a sheet flung 
across the. body. 




Fig. 37.— Delivery in side position. The hands should be gloved and the 
upper leg raised on a hard cushion or pillow. (American Text Book.) 



The hips must be brought to the edge of the bed 
while the chest and head are pulled over to the other 
edge of the bed, leaving the legs just enough space to 



142 



OBSTETRICS FOR NURSES 



double up along the side of the bed parallel with its 
long axis. 

The doctor may now sit on the edge of the bed, or 
on a high stool at the back of the patient and facing 
the buttocks. This is a most convenient and easily man- 
aged position. 

As the head is born, the faecal matter, blood and dis- 
charges must be sponged away, and the field kept clean, 
with the whole perineum visible. Always sponge from 
vagina toward rectum and throw away the sponge. 
Should the hand touch nonsterile things or septic ma- 
terial, like faeces, the glove must be changed. The 
hands must ~be kept surgically clean. 

It is a part of the nurse's duty tactfully to warn the 
doctor when such a thing occurs, as it may happen ac- 
cidentally while his attention is concentrated elsewhere, 
and a conscientious man will be grateful for the infor- 
mation. As the head passes the perineum the anaesthesia 
should be deepened. 

As soon as the head is born and the first respiration 
established (see Asphyxia, p. 278), the cord is cut and 
clamped. There is rarely any necessity for haste in this 
maneuver. The eyes are treated, and if in a hospital, a 
numbered tape is tied about the wrist and a tape with a 
corresponding number about the mother's wrist. 

The baby is now placed in the receiving blanket on 
its right side, Avith artificial warmth at its back and 
feet. The head must be lower than the body so any re- 
tained mucus can drain out of nose and mouth. Mean- 
while, the doctor (or nurse) keeps a hand on the fundus 
of the uterus to watch its contraction, see that it does 
not balloon up, and massage it occasionally if necessary 
while he awaits the onset of the third stage. 

Third Stage. — The patient is turned upon her back as 



CARE OF PATIENT AFTER LABOR 



143 



soon as the child is delivered. The pulse and face must 
be watched for signs of haemorrhage. While waiting for 
the placenta, the perineum is examined to note the de- 
gree of laceration, if any. To do this, the vulva must he 
spread apart with clean fingers so as to bring the pos- 
terior wall into view, and the discharge is sponged away 
with cotton pledgets taken from the lysol solution and 
squeezed dry. 

The patient may now have the saturated dressings re- 
moved and clean, dry ones substituted. The new pads 
catch the oozing blood and give an estimate of its 
amount. 

At this time, if desirable, the perineum can be re- 
paired. The woman is partly unconscious, the tissues 
numbed, and the needle hurts much less than it will 
later. Nevertheless, anaesthesia may be required. 

In a period varying from a few minutes to an hour, 
the hand on the uterus will note a hardening, the mass 
will become smaller, more globular, and rise slightly in 
the abdomen. A gush of blood appears at the vulva 
and usually the placenta follows. If it does not, or if 
haemorrhage or the condition of the mother requires it 
earlier, the uterus may be compressed (see Crede ex- 
pression) and the placenta constrained to deliver. 

The nurse holds a sterile basin for its reception. As 
the mass drops into the pan, the membranes drag after 
and it should be gently twisted, or the loose portions 
drawn upon until the end slips out. The placenta is set 
aside for examination, and ergot or pituitrin may be 
given to enforce the uterine contraction. The process 
of expulsion is generally assisted by a strong voluntary 
contraction of the abdominal muscles. 

After a short rest, the blood is washed off the geni- 
tals, clean linen and clean pads applied, and the abdom- 



144 



Obstetrics for nurses 



inal binder or girdle is put on to hold the pads. Warm 
blankets are thrown over the patient and within an 
hour, a glass of hot milk is administered. 

The legs should be kept together, and in case of haem- 
orrhage, the feet crossed. 

The placenta is now inspected and not only its com- 
pleteness or incompleteness noted, but anomalies of ev- 
ery kind should be looked for. 

IMMEDIATELY AFTER LABOR 

Perinorrhaphy must be done if required. 

A lacerated cervix is not to be repaired at this time, 
except in case of haemorrhage, for the tissues are greatly 
swollen, and if sutures are put in tight enough to allow 
for sufficient shrinkage, they will cut through; while if 
not tight, they will be useless in twenty-four hours. 

Care of Mother. — 

1. Cleanse genitals whn lysol solution 0.5 per cent from 
above downward. 

2. Put on sterile pad, with pad holder and binder. 

3. Wash face and hands. 

4. Take temperature, pulse, and respiration. 

5. Glass of hot milk. 

6. Keep on back four hours. Watch uterus for hemorrhage 
and keep firm by occasional massage. 

7. Put tape with case number on arm. 

Care of Child.— 

1. Clamp for the cord. 

2. Place on right side with head lower than breech. 

3. Keep warm and watch for cord lurmorrhage. 

4. Treat eyes with silver nitrate solution 1 per cent, or 
argyrol solution, 15 per cent. Do not neutralize the 1 
per cent silver nitrate solution. 

5. Put tape with case number corresponding to mother's 
on arm. 



CARE OP PATIENT AFTER LABOR 



145 



To preserve the perineum from rupture is an import- 
ant duty, and in a definite percentage of cases, unsuc- 
cessful. Nevertheless, it is a duty, which, in the absence 
of the doctor, may fall upon the nurse. How shall she 
meet it ? 

The greatest danger to the perineum comes from a 
too rapid advance of the head ; hence, the nurse retards 
the delivery by putting the woman on her side where 
she can not bear down so successfully, and instructs her 
to cry out with her pains. She may also delay the labor 
by holding the head back with a clean pad until the 
vulva stretches to its fullest capacity. 

The rules which the doctor follows in protecting the 
perineum as the head advances, may be thus sum- 
marized. 

1. Deliver the patient on her side. 

2. Maintain flexion of head. 

3. Delay extension of the head. 

4. Give chloroform to retard delivery and to prevent pre- 
cipitate delivery. 

5. Deliver between pains, if possible, by Eitgen's maneuver 
(modified). 

6. Do episiotomy, if necessary. 

Perineorrhaphy. — Lacerations of the perineum occur 
in about 30 per cent of all primiparas and in from 10 to 
15 per cent of multiparas. They occur when the child 
is large or too rapidly delivered, and when the orifice 
is small or the tissues inelastic. 

For convenience, the lacerations of the perineum are 
divided for description into three degrees. 

The first degree involves only the fourchette and a 
small portion of the mucosa. It is rarely more than one- 
half an inch in depth and requires no attention except 
cleanliness by the nurse. 

The second degree may tear a variable distance into 



146 



OBSTETRICS FOR NURSES 



the perineal body, sometimes so deeply as to expose the 
sphincter ani. It is usually on one side, but may appear 
on both sides, and be accompanied by prolongations 
into the vagina. 

The third degree passes through the sphincter and 
sometimes well up the rectal wall. This is also called 
a complete tear. 

The lacerations of the perineum which require sutures 
should be attended to at once unless the patient's con- 
dition is critical. In such cases the repair may wait 
from twelve to twenty-four hours. 

For this operation the nurse will assemble and boil 
for fifteen minutes: 

2 pairs of scissors. 

2 tissue forceps, one with teeth and one without. 
1 bull-dog forceps. 

3 artery forceps. 

6 needles, 3 full and 3 half-curved. 
1 dressing forceps. 
1 needle holder. 

Suture material of catgut and silkworm gut should 
be ready in sterile containers. The catgut should be 
the twenty-day chromicized, No. 3 and 4. Even then the 
strands are quickly absorbed when the lochial secre- 
tions flow over them. 

Silkworm gut is better, but hard to remove from the 
vagina; hence it is customary to use catgut inside the 
vagina and silkworm gut for the sutures outside. 

The nurse renews the supplies of gauze and cotton 
sponges. Hot solutions are prepared, and the patient 
brought into a position on table or across the bed so 
that the best light may be had. The legs may be held by 
the husband or nurse, or both. If help is inadequate, a 
sheet sling can be utilized. This is made by twisting 



CARE OP PATIENT AFTER LABOR 



147 



the sheet from corner to corner and passing it rope-like 
over the shoulders, and back of the neck. Then each 
end is tied above the patient 's knee on either side as the 
legs are flexed in an exaggerated lithotomy position. 

The sutures are now introduced and tied loosely from 
below upward and from within outward. If tied too 
tightly, they will cut through. The success of the oper- 
ation depends on two things: the care with which the 
levator ani, if torn, is found and restored; and the 




Fig. 58. — Sheet twisted into a sling. The patient lies on the unrolled 
portion. The rolled cords bearing against the shoulders are tied to the 
legs below the knees. See Fig. 102. (American Text Book.) 



scrupulous cleanliness obtained by the nurse in her 
after-care. If the stitches become sore, a few drops of 
sterile glycerine should be applied with an applicator. 

If catgut is used inside the vagina, the counting of 
the stitches is gratuitous, since they absorb without re- 
moval. If silkworm gut is used, the number of sutures 
must be recorded, lest one be overlooked in removal. 

Binding the legs together after repair is not required, 
but the sutures must be given aseptic care after each 



148 



OBSTETRICS FOR NURSES 



bowel movement, each urination, and when the pads are 
changed, if they have become contaminated. The su- 
tures are removed on the tenth day. 

After complete tears, the bowels are kept constipated 
for two or three days, and then moved with a high enema 



Fig. 59. — Repair of perineum. Sutures in place. (Ilammersclilag.) 



of sweet oil, followed by castor oil by mouth. After the 
bowel movement, the nurse should wash out the rectum 
with normal saline solution. The nurse must look care- 
fully at the stitches every time the pad is changed and 
note if the swelling is increasing or diminishing, if 




CARE OF PATIENT AFTER LABOR 



149 



there is irritation or tenderness, or if they are cutting 
out through the tissues. 

The external sutures are usually left long and tied to- 
gether in a knot, to prevent the ends from sticking into 
the patient. If she complains of this, the ends may be 
wrapped in sterile gauze. During the progress of the 
case the nurse must watch for and report any sign of 
fluid passing frcm bowel through the vagina. 

The perineorrhaphy being completed, the woman is 
permitted to rest though the nurse will make frequent 
examinations of pulse and respiration. She will note 
the look of the face and the hardness of the uterus. 
The pad should be watched and the amount of blood 
discharged, duly estimated. If the flow does not di- 
minish or if the uterus should balloon up, the doctor 
should be notified and the nurse meanwhile should give a 
dram of ergot (fluid extract) by mouth or an ampoule 
of aseptic ergot hypodermically. 

The doctor should remain within call of the patient 
for at least an hour after delivery. 

In the hospital the following rules may be used as 
a concise guide for the conduct of the third stage: 

Conduct op Titird Stage. 

Keep patient on back and keep a hand on fundus. Note 
amount of blood lost, its character, its flow, and whether 
steady or in gushes. The placenta should detach itself 
normally in thirty minutes. After thirty minutes, expulsion 
may be assisted by — 

(1) Early expression. 

(a) Massage, rub and knead the uterus, until it 
hardens under the hand. 

(b) Seize contracted uterus by fundus with full hand, 
fingers behind and thumb in front. 

(c) Push slowly but firmly toward the pelvic outlet. 



0 



OBSTETRICS FOB NURSES 



(2) Crede expression. 

Same maneuver as above, except that the fundus is 
compressed between thumb and fingers while the 
downward movement is progressing. 

Conditions for Crede expression: 

(a) Uterus must be contracted. 

(b) Uterus must be in median line. 

(c) Bladder must be empty. 

If not successful, wait ten minutes and then repeat maneu- 
ver. Never make traction on the cord. Never use ergot 
until uterus is empty. 

If placenta does not come away within an hour, manual 
removal must be considered. In case of haemorrhage, it 
must be removed at once. 

Carefully inspect placenta and be sure it is complete. (See 
Post Par turn Haemorrhage, p. 232.) 

When the patient is put to bed, the bloody sheets and 
towels are put to soak in cold water, and after several 
rinsings, may be sent to the laundry. Drapings stained 
with faecal matter must be cleansed separately. 



CHAPTER X 



THE NORMAL PUERPERIUM 

The puerperium is the name given to the period suc- 
ceeding the birth of the child as far as the time of the 
complete restoration of the genitals. It may last from 
six to ten weeks, or even longer if complicated. 

When the labor is completed, the most urgent desire 
of the patient is for rest. She is thoroughly exhausted 
in nerves and body. A post partum chill may appear, — 
a slight shiver that may last a quarter of an hour. Since 
the pulse and temperature remain unaffected, this phe- 
nomenon may be regarded merely as a sign of prostra- 
tion or nervous revulsion. 

In the course of the first three days, the temperature 
may rise to 100° F. in a case entirely normal. It has no 
pathological significance unless persistent or increasing. 
The temperature should be taken night and morning, 
and in complicated cases every four hours. All tem- 
peratures over 100° F., after the initial rise and descent 
just described, must be regarded as septic. 

The pulse does not rise with the temperature of the 
first three days, but remains firm or even falls a little. 
AVhen the pulse rises and the temperature sinks, it means 
haemorrhage. 

The urine is usually increased for the first few days 
and then returns to the normal for that patient. The 
labor affects the patient like a surgical operation. 

The digestion is disturbed. The appetite is gone, and 

351 



152 



OBSTETRICS FOR NURSES 



the stomach must be treated gently until its tone is 
restored. The body in repose is less urgent in its de- 
mands for food. Liquids in abundance form the staple 
diet for the first two days. For the next three days, 
semisolids may be added, and after the milk is well es- 
tablished, a general diet is desirable ; but so long as the 




Fig. 60. — The progress of involution on the various days of the puerperium. 
(von Winchkel, from Knapp.) 

mother nurses her child, the liquids must preponderate 
in most cases. 

Meanwhile, certain changes are taking place in the 
pelvis that are highly important. 

Involution is the process undergone by the uterus in 
returning to its normal nonpregnant state. This shrinkage 
can be followed abdominally and is registered by the 
nurse in the number of finger-breadths or centimeters 
above the symphysis pubis. 



THE NORMAL PUERPERIUM 



153 



Edgar gives the rate of shrinkage as follows: 

After delivery, 5.92 in. long, or 15.8 cm. 



The rate of involution not only varies greatly with 
different women, but varies much after the different 
labors of the same woman. 

Ordinarily at the end of the first week the fundus 
should lie midway between the navel and the pubes, 
and should shrink rapidly thereafter. 

The necessity for watching the rate of involution is 
imperative for a number of reasons. If involution is 
slow, or stops, it may indicate fatigue of the muscle 
from multiparity or over-distention (twins, hydramnios, 
etc.) or it may follow a post partum haemorrhage. Sub- 
involution may also indicate infection, the retention of 
clots, or pieces of placenta. It happens also when the 
woman gets up too soon or does not nurse her child and 
thereby delays the restoration of her waistline, as well 
as diminishes her resistance to disease. 

The binder is objectionable to some doctors on the 
ground that it favors retroversion of the uterus during 
involution. 

This would be a plausible theory when the uterus 
is high, if it were not that the vertebra? of the patient 
and the pelvic brim keeps the uterus from being pushed 
out of its place and after the uterus descends into the 
pelvis the gentle pressure of the binder evenly distrib- 
uted over the abdomen can not affect it appreciably. 
Furthermore, the uterus in involution shows a persistent 
tendency toward anteflexion and anteversion. 

The binder is merely a girdle put on just tight enough 



2nd day, 
3rd day, 
6th day, 
8th day, 
10th day, 



4.63 in. long, or 11.30 em. 
4.37 in. long, or 11.10 cm. 
3.42 in. long, or 8.48 cm. 
2.55 in. long, or 6.40 cm. 
2.22 in. long, or 5.60 em. 



154 



OBSTETRICS FOR NURSES 



to hold in place the bandage that supports the perineal 
pads and to allow the patient more easily to grow ac- 
customed to the sudden change in intraabdominal pres- 
sure which the delivery of the child creates. However, 
if the doctor objects to a binder, it may be left off with 
safety. 

The Lochia. — When the placenta is delivered, the 
uterus normally closes down and all gross haemorrhages 
cease; but for the next two weeks or possibly longer, a 
vaginal discharge continues. For the first few days it is 
hemorrhagic in character and it is called lochia rubra, 
and consists mostly of fluid blood with occasional small 
clots. By the fourth day, usually it has become brown 
and thinner. It is now called lochia serosa. By the 
tenth day, it is yellowish-white, and is called lochia alba. 

The lochia is the wastage from the shrinking uterus, 
and is made up of red blood corpuscles, epithelial cells, 
leucocytes, and pieces of broken-down decidual. The 
entire lining of the uterus is loosened, discharged and 
a new one formed during the puerperium. The lochia is 
regularly infected by bacteria in the vagina. If involu- 
tion is slow, the lochial discharge may be prolonged. 

The After-Pains — The puerperium is not infrequently 
accompanied by painful contractions of the uterus called 
after-pains. These are more common in multiparas and 
serve a useful purpose in maintaining a definite contrac- 
tion of the uterus. 

If the pains are at all severe, they are a suggestive 1 
symptom of the retention of blood clots, a fragment of 
placenta, or of membrane. This, of course, will occur 
either in a primipara or multipara. In all cases the 
after-pains must be differentiated from gas and from 
the pains of pelvic inflammation. 

Gas pains can be relieved by hot spiced drinks, asa- 
fcetida and the high rectal tube. 



THE NORMAL PUERPERIUM 



155 



Subinvolution is treated by the administration of fluid 
extract of ergot, in twenty to twenty-five drop doses, 
three or four times daily. This will bring about the dis- 
charge of the irritating fragment or clot, and the nurse 
can aid the process by gently massaging the uterus 
several times daily or by giving a hot vaginal douche. 
Codeine may be used for after-pains if absolutely neces- 
sary. 

Diet in Normal Cases. — There is no restriction on the 
kind of food the patient may take, so long as she can 
digest it cleanly and without gas. Acids or alkalies, 
cold or hot, rich or otherwise, fruits, meats or vege- 
tables, all go to the formation of good milk if properly 
digested. The old idea that acids should not be eaten 
is fallacious. There is more acid in the stomach nor- 
mally, than could be added in a meal made up entirely 
of citrus frnits. At the same time, the heavy foods 
should be avoided on account of the serious demand on 
the liver and kidneys in the absence of exercise. 

On the other hand, if the breasts are engorged, the 
fluids must be reduced to a minimum, and a relatively 
dry diet enforced. 

The patient loses about one-ninth of her previous body 
weight in the course of labor and the puerperium. 

The breasts are made ready for lactation twelve hours 
after delivery by cleansing with sterile green soap and 
warm water and bathing in 50 per cent alcohol. Next, 
the nipple is attended to, and the infant is put to the 
breast. 

The nipple is prepared by cleansing it with an ap- 
plicator soaked in fresh boric acid solution, and after 
nursing, the same process is repeated. This is routine, 
whether the mother is in bed or walking about. In the 
latter case, the mother must be taught to care for her 
own breasts. 



156 



OBSTETRICS FOR NURSES 



The child is put to the breast every three hours and 
given six feedings a day. This leaves a six hour interval 
at night, which is very necessary for the mother's rest 
and for the child. If the babe is feeble, seven or eight 
feedings in the twenty-four hours may be required for 
the first two weeks. 

At first the breast only secretes a thick, yellowish se- 
cretion called colostrum, of which the child gets from 
a drachm to an ounce. It is a mild laxative. 

The irritation of the nipple by the child's mouth is 
begun as early as possible in order to stimulate the 
breasts to secrete milk and the uterus to contract, and 
thus aid involution and the preservation of the ma- 
ternal figure. 

The milk usually "conies in" on the third day and is 
accompanied by a sense of distention and moderate 
pains in the breasts. The glands may be hot, hard and 
swollen, but normally there is no rise of temperature 
with the infloAV of the milk, except with nervous women 
who stand pain badly. There is no such thing as milk 
fever. If fever appears at this time, an infection must 
be suspected. 

The engorgement of the glands may become so great 
that the nipples are drawn in and nothing is left for the 
child to grasp. If the engorgement becomes too painful, 
fluids are removed from the diet list, and saline cathar- 
tics administered, while ice packs are applied to both 
breasts. Heat should never be used except for the pur- 
pose of hastening suppuration. 

This engorgement, or so-called "caking" of the breasts 
is not due to the milk, but to the infiltration of the con- 
nective tissue around the glands with serum and blood 
which stimulate the glands to secrete. The distention 
usually disappears in twenty-four or forty-eight hours, 
especially if the child is sturdy. Massage of the breasts 



THE NORMAL PUERPERIUM 



157 



only increases their activity and tends to make the 
trouble worse. 

The weight of the glands may be considerable and 
require the application of a light supporting breast- 
binder. Pillows under them will also give relief at 
times. 

In putting the child to breast, the mother should lie 
on the side with the arm raised and the child is dropped 
into the hollow thus created, facing the mother (see Fig. 
113). In this position the nipple will most easily and con- 
veniently slip into the child's mouth. The child should 
nurse fifteen or twenty minutes and then be removed. The 
toilet of the nipple is made by cleansing with boric solu- 
tion as previously described, and then placing not gauze 
but a piece of aseptic cotton cloth over it, after which the 
hinder is readjusted. (See Breast Covers, p. 326.) 

The menstrual flow ceases during lactation as a rule, 
but not invariably. The flow returns in from four to six 
weeks after delivery, if the child is not nursing, and 
about the same time after lactation ceases. There is a 
popular idea that conception can not occur during lac- 
tation, and many women injuriously prolong lactation 
in the hope of avoiding another child. The theory is 
fallacious and conception during lactation is not un- 
common. 

The Bowels. — A lying-in woman is regularly consti- 
pated. Lack of exercise, a nutritious diet, but one with 
a minimum of wastage, together with relaxed abdominal 
walls, contribute to a condition that is primarily due to 
changes in intraabdominal pressure, which follow the 
delivery. For weeks the intestines have been under 
pressure and irritation by the growing uterus, and 
when this is suddenly removed the intestines become 
sluggish. 

On the morning of the second day the patient should 



158 



OBSTETRICS FOR NURSES 



receive an ounce of castor oil. This dose, suspended in 
black coffee, beer, orange juice, or sherry wine can be 
taken by nearly everyone. In from four to six hours a 
normal saline, or soapsuds enema is given. The enema 
may be repeated daily, or if this is objectionable to the 
patient, the castor oil or Russian oil, may be given as a 
routine. Saline cathartics should not be used unless 
there is an oversupply of milk. 

There is sometimes a good deal of gas following labor, 
which can be removed by the 1-2-3 enema (see Enema, p. 
335). In giving enemas, the nurse must use great care 
to avoid touching or infecting an injured perineum. 

Many women secrete less gas and are agreeably in- 
fluenced mentally by a five grain pill of asafoetida taken 
thrice daily. 

Urination. — One of the commonest difficulties after 
labor concerns micturition. 

Owing to the swollen and bruised condition of the 
urethra and the nerves supplying the neck of the blad- 
der, the usual stimuli do not act and the woman, con- 
scious of a painful distention, is unable to pass water. 
The helplessness is increased by her position in bed. 

The nurse must make every effort to have the bladder 
emptied naturally. The process is aided by letting the 
water run from the faucet into the toilet basin, by using 
hot applications to bladder or vulva, by allowing warm, 
sterile water to run down over the vulva and perineum, 
by an enema, by putting smelling salts to the nose, by 
using slight pressure over the bladder, or by having 
Ihe patient sit up on the bedpan. 

If these measures fail and moral suasion is fruitless, 
1he bladder must be catheterized at the end of twelve 
hours. The two dangers of catheterization are injury to 
mucous membrane, and infection. Many cases of cys- 



THE NORMAL PUERPERIUM 



159 



titis have resulted from an unclean catheter or the im- 
proper use of a sterile instrument. 

To catheterize a patient, she is first given aseptic care 
during which particular attention is paid to the meatus. 
This should be cleansed with an applicator dipped in a 
solution of boric acid. Next, the nurse prepares her 
hands by scrubbing ten minutes in hot running water 
with sterile nail brush and green soap. The catheter 
either of soft rubber or glass, is boiled for fifteen min- 
utes and passed, not by touch, but by sight, and the 
flow is received in a clean basin and the amount re- 
corded. As soon as the urine ceases to flow freely, the 
tip of the index finger is placed tightly over the end 
of the catheter and the instrument is gently withdrawn. 
The finger is placed over the end of the catheter not only 
to avoid the dripping of urine as it is removed, but espe- 
cially to prevent the disagreeable sensations produced 
by the inrush of air. 

Usually one catheterization is sufficient, and every 
time the bladder fills, the nurse must take the time 
and trouble to make the patient urinate spontaneously, 
if possible, for some women form a catheter habit, from 
which it is difficult to break them. After natural urina- 
tion and after catheterization, the aseptic care should 
be repeated. 

The Genitals. — The vulvar pads should be changed as 
often as they are soiled. Four a day is an average num- 
ber, and six or eight in the first three days is not un- 
usual. Every time the pad is changed, the nurse should 
give aseptic care, and extra attention whenever the 
bowels and bladder are emptied. 

The dried secretions should be washed off with sterile 
sponges, wiping always toward the rectum and throw- 
ing away the sponge. Smegma collects in the folds of 
the labia and about the clitoris. This should be care- 



160 



OBSTETRICS FOR NURSES 



fully sponged away. If it becomes dry and hard, oil or 
albolene will soften it and facilitate its removal. Plenty 
of soap and warm water should be used, then with a 
pitcher or douche point, the whole area is irrigated 
with a solution of lysol 1 per cent. Especial care is 
given to the stitches if any are present. No traction 
must be made on the ends of the sutures, and if unusual 
soreness is complained of, the doctor should inspect 
them at his next visit. 

The nurse should be careful not to get lochia on her 
hands as the discharge contains germs which she may 
carry to herself, to the baby, or to the patient's breasts 
or eyes. 

Painful swelling of the vulva, or edema of the rectal 
protrusion may be relieved by hot boric dressings or by 
ice. bags to the anus. 

The vaginal douche is rarely employed at present ex- 
cept under specific indications. 

If the involution is slow, it is safer to use ergot by 
mouth, rather than the hot vaginal douche, as sometimes 
recommended. The douche is a frequent source of in- 
fection, as well as a useless procedure. Nevertheless, a 
dainty woman gets much comfort mentally, as well as 
physically, if she is kept clean and free from odors; 
hence if the lochial discharge becomes offensive on the 
fifth day or sixth day, as sometimes happens, a single 
hot vaginal douche may be permitted. A 1 :5000 solution 
of potassium permanganate, or a teaspoonful of for- 
maldehyde to a quart of water, or a chinosol solution 
1 :1000 may be used. 

Rest. — Since the patient will be in bed from eight 
days to two weeks in normal cases, she must be made as 
happy and comfortable as possible, and nothing con- 
tributes so much to her satisfaction as a cheerful, compe- 
tent nurse. Her mind is at ease about herself and her 



THE NORMAL PUERPERIUM 



16] 



child, and the companionship of the nurse can be made 
one of the pleasantest recollections of her illness. 

Any patient who is at all reasonable can be managed 
by a tactful nurse Avithout the consciousness of being 
opposed or directed. Gossip, hospital stories, criticism 
of other cases, other nurses, or of doctors should be 
avoided. The patient is deeply interested in her own 
case, and the private troubles of the nurse do not con- 
cern her nor enlist her attention for more than a few 
polite but unpleasant moments. 

The nerves of the patient are highly sensitized, and 
therefore she should sleep as much as possible at night, 
and take an additional nap in the afternoon. Only the 
members of the family should be allowed to see the pa- 
tient the first week, and they but for a short time. It 
takes the strength of the patient unnecessarily to see 
guests even though they be close friends. Importunate 
visitors may be pacified frequently by a view of the baby. 
The patient must be spared all household responsibili- 
ties, and if necessary, the nurse must take charge. Tact 
must be used to avoid being dictatorial, either to family 
or servants. If anything unusual arises, the nurse must 
show no surprise, annoyance, or bewilderment. Every- 
thing is attended to quietly, firmly, and without friction. 

Getting" Up. — It is a tradition that the woman is lazy 
who does not get out of bed by the ninth day. 

There are three factors to be considered, the progres- 
sive involution of the uterus, the strength of the patient, 
and the presence of stitches. Involution may be com- 
plete on the fifth day, but the prostration from the 
labor may make the woman indifferent to arising. She 
may be strong enough to rise on the third day, but the 
uterus is large and heavy, and the erect position will put 
an unnecessary strain on the supports which may retard 



162 



OBSTETRICS FOR NURSES 



involution and cause displacement or disease later. 
Also, it is not desirable for a woman to sit up until her 
perinenum is well on the road to restoration. 

In general, the woman should not get up until the 
uterus has gone down into the pelvis and is nonpalpable. 
If this is the case on the fifth day and she feels strong, 
she may get up. If she is not strong, time will be saved 
by staying in bed until her vigor returns, whether it is 
ten days or twenty. 

Getting up may be followed by a return of the bloody 
discharge. This may come from subinvolution, from, a 
relaxed and flabby uterus, from a cervical tear, or from 
change in posture. 

If there has been a retroversion before pregnancy, ly- 
ing prone with an occasional hnee chest position for a 
few moments will aid. Massage and passive exercises 
while in bed will aid the patient to recover and to main- 
tain her strength. Even after she is up and about, she 
should lie down frequently during the day and always 
when nursing the babe, until she feels quite normal 
again. 

For the hospital the following standing orders may 
be followed : 

Standing Orders — Puerperium 

Breasts : 

1. Prepare for lactation 12 hours after delivery. 

(a) Clean breasts and nipples with soapy water and 
green soap. 

(b) Sponge with sterile water. 

(c) Sponge with boric solution. 

(d) Sterile compresses over nipples and adjust binder. 

2. Babe to breast immediately after breast preparation. 

3. Every morning apply fresh compresses over nipples and 
oftener, if necessary. 

4. Cleanse nipples with boric solution (use applicator) be- 
fore and after each nursing. 



THE NORMAL PUERPERIUM 



163 



To dry up milk: 

Restrict fluids; give saline cathartics; apply ice bags to 
breasts, as needed ; for pain give codeine solution 14 to 
% gr. hypodermically, if necessary. 
Do not massage, do not bind, do not pump. Let breasts alone. 
When breast is inflamed: 

Apply ice bags constantly until pain subsides and tempera- 
ture goes down. Watch for signs of suppuration. 
Genitals : 

1. S.S. enema each morning, followed by aseptic care. 
Cleanse from above downward — 1 per cent solution of 

lysol and cotton pledgets. 

1 pledget for each side. 

1 pledget for center. 

1 pledget for rectum (last). 
External douche of sterile water. 
Dry sterile pad. 

2. Aseptic care following all bowel movements and urination. 
11<> u l ine : 

1. Record pulse and temperature twice a day, unless other- 
wise ordered. 

2. Bladder must be emptied in twelve hours. If all per- 
suasive means fail (may sit up in bed), catheterize. 

3. Make daily records of conditions of uterus (firmness and 
height), breasts and nipples. 

4. Xo vaginal douche unless ordered. 

5. Diet: liquid two days; semisolid two days; then general. 
G. Watch for haemorrhage. 

7. Keep uterus firm by occasional massage. 

8. All cases to have castor oil, 1 ounce within thirty-six 
hours after delivery (before noon). 

9. Woman may get up as soon as uterus can not be felt 
above pubes, if there is no contraindication. 

The history sheet should he kept accurately and 
should shoAV every incident in the course of the lying-in 
period. 

The condition of the bowels, bladder, and lochia, the 
temperature, pulse and respiration and the height of 
the fundus above the symphysis from day to day must 
be set down in fingerbreadths or centimeters. 

For the hospital, the following system will be found 
useful in establishing a routine. 



164 



OBSTETRICS FOR NURSES 



Nurse's Record 

First Stage. 

1. When pains began. 

2. Frequency and duration of pains. 

3. Character vaginal discharge. 

4. Time membranes ruptured. 

(a) Artificial. 

(b) Spontaneous. 

Second Stage. 

1. Time second stage began and ended. 

2. Anaesthetic. 

3. Mode of delivery. 

4. Who delivered. 

5. Sex of child. 

(a) Living. 

(b) Dead. 

6. Perineum. 

(a) Condition. 

(b) Eepair. 

Third Stage. 

1. Method. 

(a) Spontaneous. 

(b) Early expression. 

(c) Crede expression. 

(d) Manual removal. 

2. Placenta delivery. 

(a) Time. 

(b) Size. 

(c) Complete or incomplete. 

(d) Length of cord. 

3. Note. 

(a) Haemorrhage. 

(b) Quantity. 

(c) Color. 

(d) Clots. 

General condition — was case number put on mother and child? 
Other treatments. 
Medications. 
Condition of uterus. 

Temperature, pulse and respiration before leaving delivery 
room. 

Signed 

(Nurse's Name.) 



CHAPTER XI 



UNUSUAL PRESENTATIONS AND POSITIONS 

Breech Presentation. — The pelvic pole enters the inlet 
first, once in thirty cases and more commonly in primi- 
paras than otherwise. 

Etiology. — Anything that interferes with or deranges 
the laws of normal gestation will predispose to, or pro- 
duce this anomaly. 

Tims, if the head is too large, as in hydrocephalus, or 
if the foetus is too movable, as in hydramnios, or if an 
obstacle, like placenta previa, contracted pelvis or tu- 
mors prevent the proper approach of the head to the 
inlet, the mechanism will be disturbed and a breech or 
possibly a shoulder presentation will result. 

Abnormal flaccidity of the uterine or abdominal walls, 
prematurity or twins also contribute definitely to its oc- 
currence. 

The attitude of the child generally retains its normal 
aspect of complete flexion. This pose, however, is not 
maintained invariably for on occasion the buttocks and 
genitals may rest upon the inlet while one or both feet 
may be extended on the thighs and lie beside the neck, 
or the thighs may be extended while the knees remain 
flexed, and what is known as a knee presentation, or if 
the foot comes down, a footling presentation results. 

Positions. — The sacrum is the most prominent bony 
landmark of the breech, hence the positions are named 
from the relation this bone bears to the four quadrants 
of the inlet. 

"We have therefore in their order of frequency the 

165 



166 



OBSTETRICS FOR NURSES 



following designations: Left-sacro-anterior, where the 
sacrum lies to the left of the median line of the mother's 
body and in front; right-sacro-anterior, where the sa- 




Fig. 61. — The breech. Left-sacro-anterior position. (L,enoir and Tarnier.) 



crum lies to the right and in front ; right-sacro-posterior, 
where the bone lies near the mother's vertebral column, 
and on the right side ; and the left-sacro-posterior posi- 



UNUSUAL PRESENTATIONS AND POSITIONS 167 

tion, where the bone occupies a corresponding place on 
the left side. 

Diagnosis. — The recognition of this presentation is 




Fig. 62. — The breech. Left-sacro-posterior position. (Lenoir and Tarnier.) 

most easily secured by external abdominal palpation in 
pregnancy, which may be reinforced during labor by 
the internal examination. 



168 



OBSTETRICS FOR NURSES 



Externally the palpating fingers at the pelvis brim 
will note the absence of the hard, round head, and feel 
a mass, softer, quite irregular in shape, and less defined 
than customary. Movements also may be appreciated 
that would be too far down in the uterus if the head 
was presenting. 

Next the hard, spherical tumor of the head can be 
outlined somewhere in the fundus, and the heart tones, 
instead of being below the umbilicus will be on the 
same level or even higher. 

Vaginally the cervix is not filled out, the presenting 
part does not come dow r n, but after labor has begun the 
distinctive features of the breech gradually become 
more evident, as they are driven into the pelvis. 

One or both feet, or the buttocks, may be recognized. 
The examining finger may possibly enter the anus and 
be stained with meconium or pinched by the sphincter, 
which differentiates this orifice from the mouth. 

One after another the characteristic landmarks ap- 
pear until the diagnosis can not be doubtful. As soon 
as the sacrum is found or the legs definitely placed, the 
position can be named. 

Mechanism. — The hips always enter the inlet in one of 
the oblique diameters and the back is turned to the 
same part of the uterine wall as in the corresponding 
vertex positions. 

The acts described in the mechanism for vertex deliv- 
eries show a somewhat different order. Descent is first, 
then comes internal anterior rotation, which brings the 
anterior hip under the symphysis and its delivery is 
quickly followed by the posterior hip, which rolls out 
over the perineum. 

The body advances, as a rule, with the back toward 
the front of the mother. The shoulders with arms folded 



I'N USUAL PRESENTATIONS AND POSITIONS 



L69 



move under the pubic arch and then the head delivers 
in a state of flexion. The head, of course, has no caput 
and it is not moulded. 

This mechanism may be greatly impeded or compli- 
cated at any stage of the movement, The advance may 
be retarded to a pathological degree, the belly may be 
large and as it passes along the canal one or both arms 
may be stripped up alongside the head or even into the 
back of the neck. The head may be arrested at the inlet 
by the arms, by its degree of deflexion, or by pelvic con- 
traction. 

The rotation may not take place, or it may be abnor- 
mal, and the belly of the child look forward toward the 
mother's. Any of these variations adds further to the 
difficulty of the labor and to the danger of the partners 
in the event. 

Artificial aid may be required which brings with it 
the possibility of sepsis. 

The foetal mortality which averages five per cent is 
due mostly to asphyxiation. Interference with the sup- 
ply of oxygen begins as soon as the cord passes the 
vulva and the child must be delivered in eight minutes 
from that time, or perish. Partial detachment of the 
placenta may also cut off the oxygen to a fatal degree, 
and the child may be unable to breathe when born on 
account of mucus sucked into the trachea by prema- 
ture efforts at respiration. 

Minor accidents also occur, such as fractures, dislo- 
cations, and paralysis from injury to the nerve trunks. 

Management. — In the interest of the child, this pre- 
sentation is occasionally converted into a vertex by ex- 
ternal version during the last weeks of pregnancy or 
in labor before the membranes have ruptured. It is 
difficult, however, to maintain the vertex over the inlet. 



170 



OBSTETRICS FOR NURSES 



The woman must be kept quiet in a horizontal posture 
and long roller splints applied to the side of the child 
in utero and bound on. 

In primiparas, this is nearly impossible, and it is 
wiser, in the absence of some great necessity to warn 
the parents of the conditions and dangers and let them 
share in the responsibility. 




Fig. 63. — Extraction of the breech. Traction on one leg. (Hammerschlag. ) 

When the labor begins, the bag of waters must be 
kept from rupture as long as possible and when it finally 
breaks, an internal examination should be made to see 
if the cord has come down. If this happens it may be 
necessary to expedite the delivery by external assist- 
ance. 



UNUSUAL PRESENTATIONS AND POSITIONS 



171 



The doctor brings down a foot, if it is not already 
down, or pulls on the breech until the feet drop out. 
Compression of the cord must he always in mind. It is 
always compressed after the umbilicus has passed the 
navel. The shoulders are delivered by seizing the feet 
with the operating hand and swinging the body out of 
the way. This brings the posterior shoulder, which 




Fig. 64. — Breech delivery. Extraction of the trunk by pulling on the hips. 
( I Iammerschlag.) 



should be first, into the hollow of the pelvis. Extraction 
is then completed by what is called the Smellie-Veit 
maneuver. The child is put astride one arm, the first 
finger of which is hooked into the child's mouth to main- 
tain flexion. The fingers of the other hand then grasp 
the shoulders of the child astride the back of the neck 



172 



OBSTETRICS FOR NURSES 




Fig. 65. — Breech delivery. Delivering the shoulder. The body is swung 
strongly upward and outward to bring posterior shoulder into the pelvis. 
( Hammerschlag.) 




UNUSUAL PRESENTATIONS AND POSITIONS 173 



and traction is made downward in the axis of the inlet 
until the head slips into the excavation. 

If the head is delayed at the inlet, it may be neces- 
sary to put the woman in the AValcher position (q. v.) 
and for the nurse to use the Wiegand compression 




Fig. 67. — Shoulder presentation. Left-scapulo-anterior position. (Lenoir 
and Tarnier.) 



(q. v.). The feet must not be fastened in stirrups for 
breech cases. 

Forceps are not recommended for application to the 
breech as they do not fit and are liable to slip off and 
injure both child and mother. The fingers are best. 



174 



OBSTETRICS FOR NURSES 



Forceps are not recommended for the after-coming 
head unless the child is dead. If the child lives, the 
Sniellie-Veit is more successful; and if the child dies, 
the cranioclast, if possible, will save the mother much 
suffering and avoid some injury to the tissues. 

Transverse or Shoulder Presentations. — These are 
cases in which the long axis of the child lies directly 
across or obliquely across the long axis of the uterus. 

The shoulder (scapula) is the bony landmark, and 
the part which most frequently impends over the inlet. 
This presentation probably occurs once in two hundred 
labors. 

It is due to the same conditions that were given for 
breech cases; namely, weak abdominal or uterine mus- 
cles, pelvic contraction, placenta previa, hydramnios, 
and twins. 

It is easily recognized in pregnancy, and must not be 
neglected, for it is impossible of delivery without first 
changing it into a longitudinal presentation. If this 
correction is not done, rupture of the uterus is liable 
to occur, with the consequent death of both mother and 
child. 

The treatment is invariably version. 

Face and Brow Presentations. — The face presents 
once in about three hundred labors. In this case, the 
head is completely extended so that the occiput rests 
against the back of the neck. The trunk and spine are 
straightened out while the legs and arms remain in the 
normal attitude of flexion. 

The causes of these anomalies must be sought in those 
conditions which bring about the deflexion of the chin. 
The most common are pelvic contraction, large child, 



UNUSUAL PRESENTATIONS AND POSITIONS 175 

placenta previa, hydramnios, goiter, anencephalus and 
multiparity. 

Face positions take their names from the location of 




Fig. 68. — Face presentation. (Bumm.) 



the chin (mentum — Latin). Thus the most frequent 
face position is the right-mento-posterior. 

The diagnosis is not easy and may not be conclusive 



176 



OBSTETRICS FOR NURSES 



until the bony prominences of the face, such as the nose 
and orbital ridges can be distinguished by vaginal ex- 
amination. 

The delivery is protracted from three to five hours be- 
yond the average by this complication, and the mor- 
tality is higher both for mother and child. The face is 
badly swollen and disfigured, but the normal condition 
of the tissues will be restored by the end of a week. 




Fig. 69. — Descent of the chin in face presentation. (Bumm.) 



Most face cases terminate spontaneously, but operative 
interference is not infrequent on account of danger to 
mother or child. 

Version or manual correction of the presentation may 
be done before engagement. 

Forceps is the operation of choice after the head is 
fixed in the pelvis, but it may be necessary to precede 
the delivery by a preparatory pubiotomy, or in case of 
failure, to do a craniotomy on the dead child. 



UNUSUAL- PRESENTATIONS AND POSITIONS 



177 



If the chin does not rotate forward under the sym- 
physis, the labor is impossible without pubiotomy or 
live destruction of the child. In general, the case should 
be left to nature unless some definite indication to inter- 
fere develops. 

The brow presents much more rarely than the face, 




Fig. 70. — Delivery in face presentation. (Bumm.) 



possibly once in a thousand labors. It is due to the same 
conditions as bring about the presentation of the face. 
The mortality for both mother and child is higher than 
in face cases. The whole labor is harder and longer, 
besides being more dangerous to life and to tissues. 
This presentation, if recognized before the head is 



178 



OBSTETRICS FOR NURSES 



fixed, should be converted into a breech by version, but 
after the head comes down, it may be possible by hand 
or forceps to deliver either as a face or as an occipito- 
posterior, but otherwise the cranioclast must be con- 
sidered. 

Occipito-posterior position is the name given to ver- 
tex cases wherein the occiput lies in one or the other of 
the two posterior quadrants of the pelvic inlet. 

These labors are necessarily prolonged, both in the 
first and second stages, because the mechanism of de- 
livery is deranged by the larger diameters brought into 
relation with the bony canal and by the ineffectiveness 
of the contractions. 

The pains in the second stage may become violent 
and extremely painful, but the labor does not advance 
appreciably. After a little experience, mere observa- 
tion of the course of the labor will cause the suspicion 
to arise in the mind of a competent nurse that the occi- 
put is posterior. The diagnosis will be cleared up by 
the doctor's internal examination, which shows the 
large fontanelle anterior and the sagittal suture run- 
ning backward. 

The head is partially deflexed and it may not be pos- 
sible at first to find the small fontanelle. 

The position terminates by delivery uncorrected, by 
spontaneous rotation into an anterior position, or is cor- 
rected by the doctor. 

Correction should not be attempted until it is appar- 
ent that the anomaly will not right itself, which it will 
do in four cases out of five. 



CHAPTER XII 



OPERATIONS 

Complications during labor may arise from abnormal 
positions of the head, such as face or brow; from ab- 
normal presentations of the child, such as breech, trans- 
verse or shoulder; from twin labors; or from prolapse 
of a part like the foot, arm or cord. 

The mother may be responsible for some of these 
abnormalities through having a contracted pelvis, a 
rigid os, or a rigid pelvic floor. 

The uterus, too, may functionate abnormally by act- 
ing too vigorously, as in precipitate labor, or too slowly, 
as in uterine inertia. The membranes may rupture 
prematurely and produce a dry birth. 

There may be haemorrhages before labor (ante partum 
haemorrhage) during labor (intra partum), and after 
labor (post partum haemorrhage), or the labor may be 
preceded, accompanied, or followed by that extreme 
example of toxaemia known as eclampsia. 

Face and brow presentations are rare and come to the 
attention of the nurse only when an operation is re- 
quired for their relief. Further conditions may arise, 
such as danger to mother or child, which demand an ac- 
celeration of the labor. 

If the head is engaged, forceps is the operation most 
commonly undertaken, and if not engaged, the problem 
may be solved either by an early version and extraction 
or by forceps later. The dangers to the mother are 
not usually difficult to diagnose if the case has been 
followed carefully. 

179 



180 



OBSTETRICS FOR NURSES 



Signs of danger to child must 1)6 looked for con- 
stantly. Such are: 

(a) Alteration of the heart tones. 

(b) Retardation of pulse in cord between pains. 

(c) Escape of meconium is not significant unless oc- 
curring in the pain-free interval, when it may signify 
hypercarbonization of blood and a threat of asphyxia- 
tion. 

The preliminaries for the performance of these opera- 
tions may now be described, and the indications and 
conditions briefly tabulated. 

The preparation should be standardized so that the 
same set-up of the room will do for all of the major 
obstetrical operations, except Caesarean section. 

The kitchen table is generally regarded as a satis- 
factory operating table. Its length is sufficient for deliv- 
ery when the legs are doubled up. The table should be 
covered with a blanket or comfort on which it laid a 
clean sheet. A rubber blanket or piece of oil cloth is 
put on, so folded above the place for the patient's hips, 
and so pinned at the sides, that all drainage will flow 
off into a bucket or jar at the foot. 

In front of the table is placed a straight-backed 
chair with flat seat. To the right of the operator, as he 
faces the table, stands a bench, or two chairs, side by 
side; or, if possible, another table. This is covered with 
a clean sheet for the reception of the instruments. To 
the operator's left, another table similarly prepared 
carries the solutions, sponges, etc. Every operation for 
delivery should have tape and cord scissors within easy 
reach, as well as facilities for the resuscitation of the 
child. 

The light should come from behind the operator and 
fall full upon the field of operation. The room should 
be warm. 



OPERATIONS 



181 



The patient is laid upon the table and her knees ele- 
vated in the exaggerated lithotomy position. If there 
are assistants enough, one can stand on either side 
and hold a knee, if not, a sheet sling can be made 
and slung round the patient's shoulders and tied to the 
knees as previously described. 




Tig. 71.- — Exaggerated lithotomy position. The legs are held by a sheet 
sling. The vulva should be shaved. (Williams.) 



An anaesthetic will be required. If a doctor can not 
be had, this duty will fall to the nurse. 

A sterile douche bag hangs near the table. A bath 
tub of hot water must be provided and a tracheal cath- 
eter must be ready for the removal of mucus from the 
child's windpipe. An abundance of hot and cold sterile 
water must not be overlooked. In the hospital the fol- 



182 



OBSTETRICS FOR NURSES 



lowing synopsis for the placing of the linen may be 
found useful: 

Sterile Linen for Operative Case. — 

Bring patient to foot of bed. 

Put in the stirrups. (For breech deliveries do not use stir- 
rups.) 

Same order as for normal case except that feet are put 
in stirrups instead of on bed. 




Fig. 72. — Dorsal position when assistants are available. (Hammerschlag.) 

Sterile sheet under patient extends now from basin under 

bed to buttocks. 
Combination pad over field of operation. 
Sterile sheet over abdomen. 

The genitals of the patient are now cleansed with all 
care and attention described for labor. If this has 
been done within an hour, she need only be sponged 
off thoroughly with lysol solution (1 per cent). The 
feet and legs are covered with stockings, the body 
kept warm, and protected by sheets and blankets, if 
necessary. 



OPERATIONS 



183 



Every operative delivery is preceded by catheteriza- 
tion. 

All instruments are boiled for thirty minutes and 
brought to the table in the same container in which 
they are sterilized. The hot water has been poured off 
and a cool, weak solution of lysol (0.5 per cent) added. 

Forceps. — Before using forceps it should be deter- 
mined that the woman can not deliver the child un- 




A B CD 



Fig. 73. — Instruments for artificial delivery of the head. A. Braun's 
blunt hook; B, Cranicclast (Auvard) ; C, Axis traction forceps (Webster); 
D, Low forceps (Simpson). 

aided, or can not be permitted to do so without too 
great expenditure of physical and nervous energy. The 
exact conditions must be recognized as to the location 
and position of the head, the condition of the foetal 
heart tones and the size of the pelvis. When the head 
is high up, the axis-traction instrument is employed 



184 



OBSTETRICS FOR NURSES 



and patient put in Walcher's position for the traction. 

Axis traction forceps are extremely dangerous to 
mother and child, and should be avoided wherever pos- 
sible. 

The following instruments are required: 

The obstetric forceps. 

2 eight-inch forceps. 

. . fi artery forceps. . 

1 vulsellum forceps. 

1 tissue forceps. 

1 needle forceps and 6 needles. 

2 vaginal retractors. 

1 pair dressing forceps. 
1 douche point. 
1 silver catheter. 

Suture material — both catgut and silkworm gut. 

Besides these instruments, the nurse will also have 
solution basins as described for normal labor. For 
operations outside of hospitals, the nurse need not be 
clean, as her duties will consist for the most part 
in changing solutions, refilling basins, handing towels, 
etc., all of which can be done with sterile forceps. 

The following summary may be serviceable for ad- 
vanced study or reference : 

Preparation.— - 

Thorough asepsis, both subjective and objective. 

Patient should be pulled down to the foot of the labor bed 
with feet in the stirrups, or put upon the kitchen table 
or across the bed with the legs held in the. lithotomy posi- 
tion. (For breech cases, legs should not be fastened.) 

Bladder and rectum must be empty. 

Anaesthetic is necessary. 

The position of the head must be accurately known. 
Facilities for the treatment of asphyxia neonatorum must 
be at hand. 

Conditions. — 

Cervix effaced ami os dilated, except when maternal or foetal 
life is threatened. 



OPERATIONS 



185 



Bag of waters must be ruptured. 
The head must be engaged. 
The child should be living. 

Indications. — ■ 

Insufficiency of the powers of labor. 
Deep transverse arrest of the head. 
Complications in labor, such as: 

Eclampsia. 

Fever. 

Acute or chronic disease. 

Hernia — especially if incarcerated. 

Placenta previa. 

Prolapse of the cord. 

Face and brow presentations. 

Contracted pelvis. 

Occipito-posterior positions. 

Dangers From Forceps. — 

Injuries to Child. — Overeompression, especially with axis trac- 
tion forceps or in contracted pelvis. 

Crushing of soft parts, or such lesions as abrasions, pics 
sure marks, hamiatomata, swelling of face and eyelids. 

Bone injuries: Spoon-shaped depression where the head has 
been dragged through a narrow inlet; fissures in the 
parietal or frontal bones; fractures. When axis traction 
forceps are applied antero-posteriorly, the occipital bone 
may be sprung inwards until it cuts the medulla. 

Compression of the cord, especially if it is around the neck. 

Haemorrhage from the middle meningeal artery. 
Injury to eye. 
Erb's paralysis. 

Laceration of ears when the forceps are removed. 
Facial paralysis from pressure of the blade. 

Injury to Mothers. — ■ 
Infection. 

Improper application of the blades outside the cervix uteri. 

Soft parts torn by too rapid extraction. When os is not 
dilated, it is first pulled down and then torn. The tear 
may extend into the vaginal vault. Fistulae may be 
produced. 

Prolapse of the uterus from prolonged traction. 
Vaginal tears from the blades or from malplaced head. 
Slipping of blades. Traction must be not against the sym- 
physis, but down. 



186 



OBSTETRICS FOR NURSES 



The forceps commonly used in this country (Simp- 
son or Elliott) are so made that the left blade must be 
introduced first on account of the lock. 

The mortality for the child in forceps cases is about 
six per cent. 

The axis traction instrument is used but seldom by good 




Fig. 74. — Forceps operation. The left blade, in the left hand, is intro- 
duced first into the left side of the mother so that the curve of the blade 
fits the child's head (inside the cervix). (Hammerschlag.) 

obstetricians, since the danger to mother and child in 
this operation is very serious and it should be reserved 
for emergencies of exceptional character Pubiotomy may 
precede the operation with advantage in many cases. 
Asphyxia of the child and maternal haemorrhage must be 
prepared for. 



Fig. 75. — Forceps operation. The introduction of the right blade. 
( Hammerschlag. ) 




Fig. 76. — Forceps operation. Locking the handles. (Hammerschlag.) 




Fig. 77. — Forceps operation. The way the blades should grasp the foetal 
head. (Hammersohlag.) 



OPERATIONS 



189 




79. — Forceps operation. The delivery of the head. (Ilammerschlag.) 



190 



OBSTETRICS FOR NURSES 




Fig. 80. — Version. Seizing a foot. (Hammerschlag.) 

Version (Turning). — Version is a maneuver for alter- 
ing the presentation of the child while it is still in the 
uterus. A vertex may be converted into a breech, a 
breech into a vertex or a transverse into either a ver- 
tex or a breech. 

Version usually means that a transverse or a vertex 



OPERATIONS 



191 




Fig. 81. — Version. The child rotates as pressure is made upon the head 
and traction upon the foot. (Ilammcrschlag.) 

presentation is changed into a breech and is followed by 
the extraction of the child. The operation is serious 
and not to be undertaken without definite indications. 
There is always the risk of sepsis and rupture of the 
uterus as well as a high probability of a dead child. 



192 



OBSTETRICS FOR NURSES 



Perineorrhaphy is, if anything, more frequent after this 
operation than after forceps. 

Preparations. — The room and patient are arranged as 
for forceps, except that the stirrups can not be pul in. 
The legs must be held by assistants, for the deliver) of 




Fig. 82. — Version is complete when the knee appears at the vulva. 
(Hammerschlag.) 

the aftercoming head may be complicated and require 
the Walcher position, which can not be quickly obtained 
if the legs are fast. Only eight minutes are allowed for 
the delivery of the child after the navel passes the 
vulva, if it is expected to live. 



OPERATIONS 



193 



The bladder and rectum must be empty. 

Asepsis must be rigid and both subjective and objective. 

The dorsal position on a table is imperative. 

The diagnosis must be accurate and the antesthesia carried 
to the surgical degree. 

Facilities for treating asphyxia neonatorum must be pro- 
vided. 

The following summary of the indications and condi- 
tions may be convenient for reference. 

Indications. — Contracted pelvis. (Consider pubiotomy.) 

Abnormal position of the head. (Face position with chin 
posterior.) 

Prolapse of cord or an extremity with a presentation of the 

head. 
Placenta previa. 

Transverse position after the seventh month. 
Any condition requiring rapid delivery. 

Conditions. — Cervix effaced and os dilated. 

Uterus not. in tetanus nor contracted down over the child. 
The foetus must be movable. 
The head should not be engaged. 

The Walcher position is produced by bringing the pa- 
tient down to the end of the table so that the sacrum rests 
upon the edge. The thighs and legs are allowed to hang 
down of their own weight and the patient is restrained 
from falling off by traction upwards on the axilla 3 . 

In the Walcher position the diameter of the pelvic 
inlet is increased from 1/3 to T / 2 inch (1 cm.) and thereby 
the delivery of heads that otherwise could not pass 
becomes possible. 

In addition to the Walcher position other measures 
may be required to help the head through. Thus, trac- 
tion from below may be carried to the limit of safety 
and in spite of the Walcher position the head may not 
pass the inlet. 



194 



OBSTETRICS FOR NURSES 



Then" pressure from above is added. This maneuver 
will have to be executed in many cases by the nurse. 

The fingers palpate the head above the pubes. Then 
one or both fists are placed upon the abdomen over the 
head and force is exerted to crowd the head down into 
the pelvis. This is known as the Wiegand compression. 

For the operations destructive to the child, craniot- 
omy or decapitation, the same arrangements are made. 

Cranioclasis is the crushing of the foetal skull so that 



in its reduced condition the child can be delivered and 
the mother's life spared. In addition to the solutions, 
the only instruments required are the Auvard cranio- 
clast, a Naegele perforator, and a douche bag with 
glass, or any tip that can be sterilized. 

In many of these cases, both mother and child could 
be saved if seen early enough to have a Cesarean opera- 
tion. 

Decapitation is done to save the maternal life in cases 
of transverse or shoulder presentation. The prepara- 




Fig. 83. — The Walcher position. (American Text Book.; 



OPERATIONS 



195 



tions are the same as already described for forceps and 
version and the only instrument needed is a Braun blunt 
hook. (Fig. 73.) 




Fig. 84. — The Wiegand compression of the child's head to force it into the 
pelvis. (Hammerschlag.) 



Csesarean section is the delivery of the child through 
an opening in the abdomen. 

It is made necessary by contraction of the pelvic 



196 



OBSTETRICS FOR NURSES 



bones, or by the presence of a fleshy or bony mass which 
diminishes the size of the inlet. It may be required on 
account of the closure of the vagina or cervix by scars 
or on account of urgent conditions of the mother, such 
as eclampsia, heart disease, and sometimes placenta 
previa. 

The technic is simple, but good judgment must be 
used in knowing when to do it. Many operators find 
it so easy that they prefer it to the harder but safer 
obstetrical operations. 

The time of election is when the woman is at term 
but not in labor. This, of course, can be determined by 




Fig. 85. — The Naegele perforator. (Hammerschlag.) 



the history, but more certainly by careful measurements 
of the child. 

When it becomes necessary to operate on a woman 
who has been in labor a long time and especially if she 
has been examined frequently, the mortality is dispro- 
portionately high. 

It is a hospital operation, but may be done in the 
house. If not an emergency, the bowels are emptied by 
a laxative and enema the day before. Regular prepara- 
tions for laparotomy are made, plus the equipment 
necessary for tieing the cord and resuscitating the 
child. A table must be found large enough to hold the 
patient in the horizontal position at full length. Solu- 
tions of lysol 1 per cent and sterile water are placed on 



OPERATIONS 



197 



each side of the table. The instrument table carries 
towels and suture material as well. 

On a stand behind the operator is placed the hot bath 
and tracheal catheter. This center is presided over by 
someone skilled in the treatment of respiratory difficul- 
ties in the new born. Altogether, five assistants are 
required for the operation: an anaisthetizer, a clean 
nurse, and a nonsterile nurse to manage supplies, an 
operating assistant and one to take charge of the child. 

Rubber gloves must be worn by the clean assistants. 

Instruments. — 
2 scalpels. 
2 scissors. 

8 eight-inch forceps. 
10 six-inch artery forceps. 

4 sponge carriers. 

4 tenaculum forceps. 

2 rat-toothed tissue forceps. 

4 full curved round needles for uterine wall. 

4 smaller needles for the fascia. 

2 Hagedorn needles for the skin. 

2 needle holders. 

1 dressing forceps. 
Plenty of suture material, both catgut (No. 3 and 4) and 
silkworm gut for the abdominal wall. 

Supplies. — ■ 

1 doz. laparotomy sponges with metal rings sewed in or 
a long tape attached, 
large laparotomy pads. 
1 large pillow slip full of sterile cotton. 
Sponges. 

1 laparotomy sheet. 
1 dozen towels. 
1 pair of leggins. 

Gowns and head dressings (gauze will do) for the operator 
and assistants; rubber gloves, basins and accessories. 
All are sterilized. 

If the woman has been examined, the vagina should 
be sponged out with tincture of iodine. The abdomen is 



198 



OBSTETRICS FOR NURSES 



shaved, scrubbed with green soap, nail brush, and hot 
water for five minutes. It is then rinsed with ether and 
painted with iodine. 

The presentation of the child, the presence and location 
of the heart tones must be determined before operation. 

The patient is anesthetized with ether, chloroform or 
gas. 

The incisions are made; the child delivered to the 
proper assistant; the placenta and membranes removed; 
the sponges counted ; and the uterus and abdominal wall 
sutured. 

After-care. — The nurse watches the patient for sigh- 
ing respiration, rapid pulse, pallor, and other symptoms 
of hemorrhage, either external or internal. Artificial 
heat is supplied. Haemorrhage from vagina should be 
looked for. It is normal. Salt solution by hypodermoclysis 
may be required. Hot water by mouth in small sips or tap 
water by rectum (drop method) will relieve the thirst. 
Morphine may be given if pain is extreme. An enema 
may be given on the second day or calomel may be 
started in the morning of the second day. Distention 
from gas, with or without nausea and vomiting, hic- 
cough and rise of temperature are all signs of danger. 
No milk should ever be given on account of the gas it 
causes. 

The child is put to breast as usual after twelve hours. 
The stitches are to be taken out on the tenth or 
twelfth day. 

Symphyseotomy is a separation of the pelvis at the 
pubic joint and is done with a scalpel or a specially de- 
vised knife. 

Pubiotomy is the division of the pelvis, three or four 
centimeters to the right or left of the pubic joint. The 
division passes through the pubic bone and is usually 



OPERATIONS 



199 



done with a serrated wire called the Gigli saw. It is 
introduced subcutaneously by a special instrument 
called a pubiotomy needle. Both symphyseotomy and 
pubiotomy are preparatory to delivery. Pubiotomy is 
the more desirable and successful operation. The ends 
of the severed bones separate from one and a half to two 
inches, and the child delivers easily through the en- 
closed opening. The after-care is usually simple. 

Instruments. — 

1 scalpel. 

2 Gigli saws. 

1 pubiotomy ueedle. 
(i artery forceps. 

3 eight-inch forceps. 

1 needle holder. 

2 retractors. 

Suture material and sponges as usual. 

The hips are strapped in circumference with zinc ad- 
hesive plaster to support the bones. 

The danger of infection of the wound from the lochia 
is always present. The main difficulty is in moving the 
patient, who is more than usually helpless. The bony 
ring of the pelvis is broken and she can not raise her 
leg. The repair is cartilaginous at first, but solidifies 
in a few months so that locomotion is not impaired. Es- 
pecial pains must be taken to avoid bed sores. 



CHAPTER XIII 



MINOR OPERATIONS 

Aseptic Care. — Place patient on a clean bed pan. It 
need not be sterile. Drape with a sheet and arrange it 
so the fold may be easily raised by nurse's elbow. Have 
sterile basin with cotton pledgets to be filled with solu- 
tion of lysol 1 per cent. Lysol must be put in basin 
first and the water added. Take to bedside. Nurse 
scrubs her hands ten minutes with a sterile brush, hot 
water, and green soap. Use no towel, no gloves. Keep 
hands wet and clean. Cleanse vulva with wet pledgets 
from above downward. Apply sterile pad. 

Sterile Specimen. — To get a sterile specimen of urine 
without catheter, give aseptic care, tampon vagina with 
large pledget of sterile cotton. Have patient urinate in 
a sterile basin. Remove tampon. 

Sterile Specimen from Child. — Take a glass test tube 
and thrust its round end through a hole in a square 
piece of adhesive plaster. Push it down until the plas- 
ter is caught and stopped by the enlarged rim at the 
month of the tube, with adhesive side of plaster on same 
side as opening of tube. Fasten the tube over the male 
penis or female vulva by applying the plaster to the sur- 
rounding skin. Leave until full. 

Aseptic Douche. — Boil douche point and basin. 
Leave point in sterile basin. Fill douche can with 
sterile water, temperature 104° to 110° F. Put clean 
bedpan under patient Avho is draped with a sheet. 
Have at hand a sterile basin containing solution of 

200 



201 



MINOR OPERATIONS 



lysol 0.5 per cent, or boric acid 5 per cent in which cot- 
ton pledgets are immersed. Scrub the hands as for asep- 




Fig. 80. — Apparatus for getting a sterile specimen of urine from an infant. 

tic care. Cleanse the vulva with cotton pledgets, wash- 
ing always toward the anus, and use each pledget but 
once. Adjust the douche point and introduce it just 



202 



OBSTETRICS FOR NURSES 



inside the labia. The douche can should be only a trifle 
higher than the pelvis. When can is empty, apply a sterile 
pad. 

If the douche is to be used as a deodorant after the fifth 
day of the puerperium, either of the following solutions 
may be employed : Potassium permanganate, 1 :5000 ; 
formaldehyde 1 dram to quart, or chinosol 1 :1000. 

The vaginal douche may be used in cases of gonor- 
rhoeal infection in pregnancy during the last weeks, in 
the hope of avoiding infection of the child's eyes. 

It is given like the aseptic douche (q. v.) with potas- 
sium permanganate 1:5000, or chinosol 1:1000. It should 
be hot (112° to 120° F.), and be begun not long before 
term, so that in case labor conies on, the danger to the 
child will be minimized. The reservoir must not be too 
high, nor the douche point inserted much beyond the 
labia. The woman should be on her back and the 
douche point should be rubber or glass. 

Removal of Sutures. — On, or about, the tenth day the 
removal of sutures is required. 

The nurse will sterilize by boiling, 1 pair of long- 
handled, sharp-pointed scissors, 1 pair of tissue forceps, 
and if the sutures extend far into the vagina, a vaginal 
retractor. 

A basin of lysol solution (1 per cent) with cotton 
sponges, a sterile towel to lay the instruments on, a 
dish to receive the soiled dressings, sutures and dis- 
carded sponges, completes the arrangement. 

The patient is now draped with sheets as for exam- 
ination. The doctor prepares his hands as for operation. 
The nurse holds the limbs of the patient in lithotomy 
position and the operation is begun. 

Uterine Tampon. — Packing the uterus is mostly em- 
ployed for haemorrhage after labor. The patient, there- 



MINOR OPERATIONS 



203 



fore, has been prepared and only fresh sponging with 
lysol solution is required. 

The instruments are, 1 vaginal retractor, 1 pair of 
dressing forceps, 1 vulsellum forceps and a jar of gauze, 
four to six inches wide and ten or twelve feet long. Al- 
ways use a single continuous strip. A very large quan- 
tity is necessary to fill the uterine cavity. Any sterile 
gauze may be used, bnt weak iodoform is satisfactory. 




Fig. 87. — Tampon of the uterus. (Hamnierschlag.) 



The vagina is held open with retractors, the cervix 
seized with a tenaculum and pulled down, the end of 
the gauze strip is then carried into the uterus as far as 
the fundus, the dressing forceps withdrawn and a new 
length carried in until the cavity is packed tightly from 
the fundus clear to the os. 

Care must be taken that the strip of gauze is not con- 
taminated by vaginal contact during the introduction. 
A. pad and binder are now applied. If no instruments 
are at hand, or there is not time to sterilize, then the 



204 



OBSTETRICS FOR NURSES 



nurse can grasp the fundus through the abdominal wall 
with her hand and push the cervix down to the vulva 
where the gauze can be pushed in by the doctor's fing- 
ers, if necessary. 

The tampon acts as a haemostatic through its direct 
mechanical pressure, and dynamically by stimulating 
the uterus to contract. It should be removed in from 
twelve to twenty-four hours. 

To tampon the vagina the woman lies on her back 
across the bed, with her feet on the knees of the doctor, 



- - - 




Fig. 88. — Tampon of vagina. (American Text Book.) 

who sits facing her. A sterile retractor holds back the 
posterior wall of the vagina. 

With a pair of dressing forceps the doctor seizes the 
pledgets of cotton or gauze out of the lysol solution 
and carries them one by one as far as they will go, in 
various directions around the cervix. One is pushed 
forwards toward the bladder, the next back toward the 
rectum, the next in the middle, and so on until no more 
can be introduced. A pad and binder are applied 
tightly. 



MINOR OPERATIONS 



205 



The uterine douche is sometimes employed for haemor- 
rhage. The field of operation and the doctor's hands are 
prepared as usual. The nurse cools the boiled douche 
water down to 120° F. and if ordered, adds 2 drams of 
sterile salt to each quart. 

The instruments are a vaginal retractor, a long uter- 
ine douche point, and one vulsellum forceps. 

The cervix is seized and brought down, the long 
douche point connected with the tube from the reservoir 
is carried to the fundus and the water started. Care 
must be used that the return flow is free and unob- 
structed. 

This method is most satisfactory in uterine haemor- 
rhage after the uterus has been entirely emptied. It 
stimulates a prolonged and profound uterine contrac- 
tion. 

Intravenous Injections. — The vein in the front of the 
elbow is usually chosen. (Median basilic or median 
cephalic.) A rubber bandage or tourniquet is wound 
tightly about the middle of the upper arm to make the 
veins stand out prominently. The surface of the skin 
should be sterilized for operation by scrubbing with 
green soap and hot water and rinsing with 50 per cent 
alcohol, followed by 1:2000 solution of bichloride, or 
by the application of tincture of iodine. 

The hypodermic needle is then introduced after ex- 
pulsion of all the contained air and the piston is drawn 
up until the blood enters. This assures the operator 
that the needle has entered the vein. The bandage is 
now loosened and the solution of the drug is introduced 
very slowly. 

Intravenous infusion or transfusion is given in the 
same way. The fluid (normal saline?) must be running 
from the needle as it is introduced. 



206 



OBSTETRICS F0R NURSES 



Hypodermoclysis is the introduction of normal saline 
solution, under the skin, or under the breasts. The so- 
lution may be transfused also into a vein. 

By this operation, the quantity of fluid in the ves- 
sels is greatly increased and a circulatory stimulant is 
provided. Normal saline also promotes diuresis and 
aids in the removal of wastage. 

The principal dangers arise from too great rapidity or 
too large a quantity of the flow. 

The skin should be sterilized at the point of attack 
by a coating of tincture of iodine. 

The instruments required are, a bath thermometer, a 
douche can (fountain syringe) with long tubes and an 
aspirating needle. A hypodermic needle will do, but 
the reservoir must be well elevated since the caliber is 
so small. Ordinarily the reservoir need be held only two 
or three feet above the point of discharge. The water 
should be flowing through the needle when it enters the 
tissues. If the fluid is to be introduced under the skin, 
the best place is in the loose region between the hips 
and the ribs in front. If under the mammary gland, the 
needle must go below and under the gland from the out- 
side edge, not into the gland. If into a vein, such addi- 
tional instruments will be needed as a rat-toothed tis- 
sue forceps, a pair of sharp-pointed scissors, a knife and 
some fine catgut. From four to sixteen ounces of fluid 
may be used at a temperature varying from 105° to 
110° F. 

The openings where the needles entered are closed by 
cotton and collodion. 

Curettage of uterus is done for abortion or puerperal 
sepsis when foreign fragments are left in the uterus. 
The room is prepared as for delivery. 



MINOR OPERATIONS 



207 



The instruments are: 

1 vaginal retractor. 
1 vulsellum forceps. 

1 long uterine douche point. 

2 dull curettes. 

2 sharp curettes of different sizes, together with gauze 
for packing the uterus. 

Rubber gloves should be worn both by nurse and 
physician as much for personal protection as for the 
patient's safety. In many cases of incomplete abortion 
or of puerperal sepsis the endometrium is more satisfac- 
torily curetted with the gloved fingers. 

Abortion may be indicated in many of the early com- 
plications of pregnancy, such as hyperemesis, nephri- 
tis, uncompensated heart lesions, tuberculosis, insanity, 
hydramnios, incarcerated retroversions of the uterus 
and the presence of hemorrhage. These cases require 
the operation to be undertaken and finished by the doc- 
tor, but other conditions develop wherein, without voli- 
tion on the part of the patient or doctor, the abortion 
begins. Some may be saved, but at times the attempt is 
futile. 

If the emptying of the uterus seems inevitable, the 
function of the physician is to see that the process is 
finished as quickly and cleanly as possible. 

This may be done in the early stages by packing the 
cervix and vagina with iodoform gauze and administer- 
ing ergot in twenty-five drop doses thrice daily. 

In case of dangerous haemorrhage from spontaneous 
abortion, the vagina can be tamponed with cotton pled- 
gets or gauze by a clean nurse Avhile awaiting the ar- 
rival of the doctor. 

When the uterus has partially emptied itself and the 
retained fragments prevent the complete contraction 
and allow of serious bleeding, or if the fragments are 



208 



OBSTETRICS FOR NURSES 



septic, then their removal is required. This is done by 
the finger or curette. 

The preparation of rooms, patient and doctor are the 
same whether the operation is for therapeutic or incom- 
plete abortion. These have been described. 

The instruments are: 

1 pair dressing forceps. 

2 vaginal retractors, 
artery forceps. 

2 curettes of different sizes. 

2 vulsellum forceps. 

1 long uterine douche point. 

1 pair Goodell dilators. 

1 douche can. 




Fig. 89. — Pean forceps. 



The induction of labor at or near term is done for 
pelvic contraction, maternal disease, for danger threat- 
ening mother or child, or to avoid the birth of a post- 
mature child. A variety of methods may be employe* I, 
but the Vorhees bag is best. 

Technic. — Assemble, and sterilize by boiling twenty 
minutes, a Vorhees bag No. 3 or 4, Simon speculum or 
vaginal retractor, 1 pair long Pean forceps, 2 pairs 
vulsellum forceps, 1 dressing forceps, 2 pairs compres- 
sion forceps, 1 Goodell dilator, 1 tenaculum forceps, 
Davidson hand bulb syringe with "lass tubes and rub- 
ber connections for the bag. 

Patient, prepared as for delivery, is placed upon the 



MINOR OPERATIONS 



209 



table in exaggerated lithotomy position. Stirrups will 
serve. 

The vagina is retracted, a smear made from cervix, 
and the mucous membrane wiped clean with pledgets 
of gauze on forceps. 

Anaesthesia is only occasionally necessary even in pri- 
mi paras. 




A BCD 

Fig. 90. — A, Hand bulb syringe; B and C, Vorhees bags; D, Bag rolled 
and grasped by Pean forceps ready for introduction. 



Before using, the apparatus must be tested by forcibly 
filling the bag with sterile solution. 

One lip and sometimes both are seized by vulsellum 
forceps and brought down. Usually, even in primiparas, 
the os is sufficiently patulous to admit the bag — if not, 
dilate. 



210 



OBSTETRICS FOR NURSES 



The bag, emptied of residual air and fluid, is rolled up 
into a compact mass like a cigarette, seized with Pean 
forceps so that the tips extend just to the end of the 
bag. Turn the concavity of forceps toward patient's left 
leg and introduce. As the bag enters turn the mass to 
the left — a quarter turn — so that when operation is 
completed the forceps curve faces upward. Release the 




Fig. 91. — Vorhecs bag in place. 



lock on forceps. Connect the tube of the bag with syr- 
inge tube and force the solution slowly into bag. 
Pean forceps may be removed as bag fills. Remove vul- 
sellum. Tie tube of bag with tape when bag is full — 
disconnect syringe. Put sterile pad on either side of 
tube. 

If pains do not start within an hour, or if compres- 
sion is desired as in placenta praevia or a more rapid 



MINOR OPERATIONS 



211 



dilatation, then a weight of one or two pounds is at- 
tached by a tape to the protruding tube and passed over 
the foot of the bed. 

Digital dilatation of cervix may be indicated in cases 
of rigid os or where prolonged labor or some danger to 
mother or child requires the hastening of the delivery. 

No instruments are needed, but a complete anaesthetic 
is necessary. 

Thorough asepsis must be observed. The patient's 
genitals and the doctor's hands are prepared as de- 
scribed for labor, and rubber gloves are imperative. 

The gloved hands and the vagina and vulva are well 
rinsed with lysol solution 1 per cent. The operation 
must be done carefully, patiently and gently, lest the 
cervix be lacerated. 

The hand is introduced into the vagina, and first the 
thumb and index finger are introduced into the os 
and separated as widely as possible, then the second 
finger and so on, until the dilatation is complete. (Hirst's 
method.) 

Another method is the introduction of the tips of both 
index fingers, back to back. Force exerted will dilate 
the canal so second fingers may also be inserted. Then 
patiently and gently the rigid ring of the os is overcome. 
(Edgar's method.) 

Episiotomy. — This is a clean incision of the vulva, 
which is done to avoid an apparently inevitable and 
ragged tear of the perineum. 

The instruments required are either a blunt tipped 
knife or a pair of blunt scissors. 

The operation may be done on one or both sides de- 
pending on the amount of room required. The incision 
begins at a point just above the lower third of the 
vulvar outlet when distended by the head, and passes 



212 



OBSTETRICS FOR NURSES 



obliquely downward and outward. This severs unim- 
portant tissues only, instead of allowing the valuable 
perineal body to suffer. It makes a clean wound that 
heals readily, instead of a ragged tear through bruised 
tissue. The cut is high enough to be free from the 
constant bath in infectious lochia, which troubles the 
healing of the usual perineal laceration. 




Fig. 92. — Episiotomy. (Hammerschlag. J 

Rectal Infusion (Drop Method). — A douche bag con- 
taining normal saline solution is hung near the bed and 
kept warm with an electric pad, a hot flatiron, or by a 
hot water bag on either side. The tube ends in a cathe- 
ter which is inserted into the rectum. The tube is 
clamped so that only a drop of solution can escape each 
second. 



MINOR OPERATIONS 



213 



Wet packs are both sedative and antipyretic and may 
be employed for a local or a general effect. 

For bronchitis the pack may be applied to the chest 
only as follows: The child (or adult) is stripped in a 
warm room (75° F.) and the chest swathed front and 
back with a thick towel wrung out of hot water (tem- 
perature 105° to 110° F.) Over this a woolen shirt may 
be drawn or a blanket wrapped, and the patient put to 
bed. After six or eight hours, the dressing is removed 
in a warm room, a hot bath administered, and the body 
well rubbed with alcohol, and dried. The treatment 
may be repeated if necessary. Do not burn the patient 
by applications too hot. 

The general pack is most serviceable in reducing tem- 
perature and producing a diaphoresis to relieve the kid- 
ney and cleanse the system, as in eclampsia. For this 
purpose the entire body, naked, is rolled in a sheet 
wrung out of hot water and then put between heavy 
blankets in bed. The pulse should be taken frequently 
and the temperature recorded at intervals. A cool ap- 
plication to the head is very soothing. 

The patient sweats profusely and hot drinks may be 
given to promote a more abundant diaphoresis. Usually 
the patient drops off to sleep as the fever subsides. 
Twenty to forty minutes is the average duration of such 
a treatment. 

When the pack is removed, the patient is wrapped at 
once, without drying, in warm blankets, and left for an 
hour or so. 



CHAPTER XIV 



COMPLICATIONS IN LABOR 

Pelvic contraction is not infrequently the cause of 
difficult or prolonged labor. The deformity is most com- 
monly clue to rickets in childhood. 

There are many forms of pelvic contraction, but in 
this country only two are at all common ; the generally 
contracted, and the flat pelvis. 

The generally contracted pelvis is, in the main, a well 
shaped pelvis, only its measurements are smaller than 
normal. 

The flat pelvis is marked by a shortening of the an- 
teroposterior diameter of the inlet. It looks as if it 
had been pressed together from before backward while 
in a soft condition. 

These and other deformities will be recognized in ad- 
vance of labor by the routine application of the pelvi- 
meter. 

The value of this instrument is so great, that no com- 
petent man does obstetrical work at the present time 
without using the pelvimeter as a routine. 

The average diameters in normal pelves may be tab- 
ulated as follows: 

Interspinous — between the anterior superior iliac 
spines — 25 cm. 

Intercristal — between the iliac crests — 28 cm. 

External conjugate — taken from the upper border of 
the symphysis to the depression below the last lumbar 
vertebra — 20.5 cm. Take 9.5 cm. from this to get the 
true conjugate. 



COMPLICATIONS IN LABOR 



215 




Fig. 93. — Various forms of pelvic deformity compared with the normal 
inlet. (liumra.) 



The circumference of the hips just below the iliac 
crests and above the trochanters — 90 cm. It is taken 
with a tape line. These are the usual external measure- 
ments. 

The internal measurements are made with the fingers. 
The diagonal conjugate is the distance from the lower 



216 



OBSTETRICS FOR NURSES 




Fig. 95. — The various diameters of the inlet with the lengths given in 
cubic centimeters. (Williams.) 



COMPLICATIONS IN LABOR 



217 



border of the symphysis to the promontory of the sa- 
crum. It should measure 12.5 em. The first and second 
fingers are passed into the vagina and pushed up until 
the tip of the second finger touches the promontory of 




Fig. 96. — Measuring the distance between the anterior superior spines of 
the pelvis. (Williams.) 

the sacrum. The finger of the other hand marks the 
depth of the examining fingers just below the sym- 
physis. The distance is measured when the finger is with- 
drawn, and 1.5 cm. is subtracted. The result is the true 



218 



OBSTETRICS FOR NURSES 



conjugate. These measurements carefully made and 
the deduction judicially estimated, give one a fairly ap- 
proximate idea of size and shape of the pelvic inlet. 
The aim of nearly all the pelvic measurements is to get 




Fig. 97. — Measuring the external conjugate. (Williams.) 



not only the size and shape of the inlet, but so far as 
possible, a working estimate of the anteroposterior diam- 
eter of the brim, which is the most important of all the 
diameters. In normal cases this should be 11 cm, 



COMPLICATIONS IN LABOR 



219 



Thus, taking 9.5 em. from the external conjugate 
(20.5 cm.) gives 11 cm. 

Subtracting 1.5 cm. from the diagonal conjugate as 
obtained with the fingers as above described, (12.5 cm.) 
gives 11 cm. The subtraction is made to compensate 
for the thickness of the pubic bone and its inclination 
outwards. 

A circumference of 90 cm. corresponds to an inlet of 




Fig. 98. — Measuring the diagonal conjugate with the finger. (Eden.) 



11 cm. in its anteroposterior diameter, and every varia- 
tion of 5 cm. in this circumference makes a difference of 
1 cm. (either larger or smaller) in the anteroposterior 
diameter. 

Thus, 95 cm. in circumference = 12 cm. in the diam- 
eter ; and 85 cm. in circumference = 10 cm. 

Complications increase in proportion to the degree 
of contraction in the pelvis. 

The most frequent difficulties superinduced by the 



220 



OBSTETRICS FOR NURSES 



small pelvis are prolapse of the cord, malpresentation 
and malpositions of the head, prolonged labor, and a 
large increase in the number of assisted deliveries. 

All the possibilities and probabilities in a given case 
Avill be carefully worked out before labor by the con- 
scientious obstetrician, and Caesarean section, induction 
of premature labor, pubiotomy, forceps, or version and 
extraction, will be done with a sure foreknowledge. 

Prolapse of the cord complicates labor once in about 
two hundred cases. It is most likely to occur when the 
presenting part does not enter or does not entirely fill 
the opening, as in transverse or shoulder presentations, 
or vertex presentations with small inlets. 

The mother is not endangered by this mishap, but the 
babe is lost in from 35 to 60 per cent of the cases. 

The diagnosis is easily made when a loop of cord pro- 
trudes from cervix or vulva, and the pulsation will dif- 
ferentiate it from everything else. 

If the cord does not pulsate, the family should be in- 
formed that the child is dead and the ease may be al- 
lowed to terminate normally. 

If it still pulsates, the woman should be placed in 
the knee-chest position for ten or fifteen minutes, then 
upon the side, opposite to that on which the cord has 
prolapsed, and back again as soon as possible to the 
knee-chest position. A chair may be used to produce a 
Trendelenburg position by placing it so that the edge of 
seat and top of back rest on the bed. Then the patient 
puts her legs over the lower rungs and lies with her 
back against the chair back and her head on the bed. 

If the cervix is effaced and the os partly dilated, re- 
position may be attempted either with the finger or a male 
catheter. 



COMPLICATIONS IN LABOR 



221 



The operation will, of course, succeed most easily if 
done in the knee-chest position, with gravity to aid. 

If the cord can be pushed back, a Vorhees bag may 
be inserted to keep it from coming down again. This 
holds back the cord, dilates the canal and stimulates 
the pains. 

When the bag comes out, version and extraction can 
and should be done at once. 

In general, the following summary may be useful: 

Prolapse of Cord 

Cruises. — 

Contracted pelves. 

Breech and transverse presentations. 

Malposition of bead, or face and forehead presentation. 

Hydramnios. 

Accident. 

Low insertion of placenta. 
Diagnosis. — ■ 

Before rupture of membranes careful examination will show 

pulsating cord in advance of head. 
After rupture the cord may be felt in vagina. 

Dangers. — 

To mother: — None but those due to causative condition. 
To child: — Compression of the cord and asphyxiation. 
Contraction of exposed vessels of cord. 
Patient may lie on cord. 

Twenty five per cent die as a rule under best conditions. 
Fifty per cent when left to nature. 

Treatment of Cephalic Presentation. — 

Extraction of child or reposition of cord, depending upon 

the degree of dilatation. 
If cervix is small, replace and fill cervix with Vorhees bag. 
When cervix admits hand, either replace or do version and 

extraction. 

With head engaged, reposition or version is not possible. 

Child living: — Rapid delivery with forceps. 

Child dead: — Craniotomy or leave to nature. 

Prolapse of one or both hands may take place. If the head 

is engaged, no interference should be attempted. If not, 

replacement or version may be done. 



222 



OBSTETRICS FOR NURSES 



The soft parts may also complicate the labor process. 

No time need be spent here on the rarer forms of ob- 
struction due to uterine or ovarian tumors. 

Rigidity of the cervix, or os is not uncommon. 

This may be due to a dense, almost cartilaginous con- 
sistence of that tissue, to premature rupture of the bag 
of waters, to weak, inefficient contractions in the first 
stage, or to a steel-spring-like contraction of the mus- 
cular fibers of the os. 

In all cases the first stage of labor is greatly pro- 
longed, but so long as the membranes are intact, the 
child is in no danger. 

Two kinds of cases are met with, those in which the 
pains are violent, and those in which they are weak 
and shallow. In the first class, as soon as the condition 
is recognized, a dose of morphine sulphate, 1/6 gr. and 
scopolamine hydrobromide 1/150 gr. should be given hy- 
podermically. The rigid ring relaxes under the influence 
of the narcotic, and labor proceeds rapidly and almost 
painlessly. Chloroform may be substituted if the mor- 
phine and scopolamine are not at hand. If the cervix 
is effaced and only the rigid ring of the os prevents the 
completion of the labor, or if the above methods fail, 
then the patient may be anaesthetized and the rigidity 
overcome by the fingers. This is an emergency that 
should not be attempted until all else has failed and 
some danger arises that makes it necessary to hasten the 
delivery. (See Minor Operations, p. 211). 

Where the constriction is due to unusual density of 
the cervix or to cicatricial tissue, it is sometimes neces- 
sary to make incisions under aseptic precautions so 
that the rigid ring may expand. 

Weak and inefficient contractions can sometimes be 



COMPLICATIONS IN LABOR 



223 



stimulated satisfactorily by the introduction of a Vor- 
hees bag. 

Rigidity of the pelvic floor may be due to inadequate 
elasticity of the tissues as in old primiparas or in young 
women who have ridden horseback for many years in 
the cross-saddle position. 

The head may come down to the pelvic floor but will 
not advance further. If the tissues of the vulva do not, 
or can not yield sufficiently after appropriate time has 
been allowed, episiotomy may be done. (See Minor 
Operations, p. 211.) 

The uterus itself may functionate abnormally. 

Precipitate labor is an over rapid advance of the child 
wherein the stages of labor are merged into one another 
and the child expelled in two or three pains. 

It may be due to unusual capacity of the pelvis, or 
to strong contractions which the patient is not aware 
of, or both. These cases predispose to post partum 
haemorrhage and to serious lacerations of cervix and 
perineum. 

The child is usually delivered in an undesirable place, 
such as a toilet basin or a street car, and perishes from 
the fall, from cold, from umbilical haemorrhage, or lack 
of facilities for revival. 

The nurse who is watching a case is responsible for 
the prevention of a precipitate. If the event impends, 
the woman must be placed upon her side with legs 
straight, and she should be instructed to cry out with 
every pain. Chloroform may be given and the head 
forcibly held back. 

Uterine Inertia. — A sluggish state of the uterus may 
characterize the labor and the contractions will be slow, 
shallow and inefficient. The intervals may be pro- 
longed, although the patient complains bitterly of pain. 



224 



OBSTETRICS FOR NURSES 



The condition is seen most frequently in multiparas and 
is due to defective innervation of the uterus or to im- 
perfect reflexes, and in primiparas also it may he due to 
the newness of the function that is suddenly called into 
play, or to contracted pelvis. Many times the trouble 
results from overfatigue and want of sleep. If this is 
the case, the remedy may be found in the administra- 
tion of morphine sulphate 1/6 gr. and scopolamine 
1/150 gr. The pains are diminished or abrogated while 
the contractions continue. The scopolamine may be re- 
peated if necessary. Under proper indications and con- 
ditions this treatment is harmless, both to mother and 
child, but requires supervision on the part of the nurse 
or physician. 

If the patient is not overly fatigued, the introduc- 
tion of a Vorhees bag, as described under the head of 
Induction of Labor (p. 208) will dynamically increase 
the strength and frequency of the contractions, mechan- 
ically aid the effacement of the cervix and the dilata- 
tion of the os, and shorten the first stage anywhere from 
six to twelve hours. 

As soon as the os is dilated, pituitrin may be given 
under due precautions, as hereafter indicated. Pitui- 
trin has but little influence on the nonfunetionating 
organ, but acts well on a uterus which is definitely con- 
tracting. It should not be given during the first stage, 
since when the uterus contracts, there must be an ade- 
quate opening for the advance of the child. Five to 
seven minims is the usual dose, injected into the deltoid 
muscle. The injection may be repeated in an hour, if 
required, since the effects, which begin about five min- 
utes after the injections, will pass off in fifty-five 
minutes. 

By the use of pituitin many operative procedures are 



COMPLICATIONS IN LABOR 



225 



altered or avoided. A high forceps case may be con- 
verted into a case for the low instruments, and the latter 
in many instances avoided altogether. 

The use of pituitin may be briefly summarized as fol- 
lows: 

Pituitrin 

(Use no alcohol to cleanse syringe or skin before injection.) 
Indications. — 

1. Inertia uteri or weak, shallow pains in second stage. 

2. Multiparity. 

3. Post partum haemorrhage. 

4. To avoid use of forceps or to reduce a high forceps case to 
a low one. 

5. Cesarean section. 

If the patient is a multipara, sterile linen should be on and 
attendants ready for the delivery before an injection is 
given. 

Conditions. — 

1. Cervix effaced. 

2. Os admits three fingers. (Better if membranes have rup- 
tured.) 

3. Head should be engaged. 

4. No mechanical obstacle to delivery such as tumors or 
markedly contracted pelvis, etc. 

Dangers of Long Labors. — 
Compression of cord. 

j Vesicovaginal fistula?. 
Necrosis of maternal tissues. -j Rectovag , inal iistula ,. 

Infection— peritonitis. 
Necrosis of skin over skull. 
Necrosis of cranium. 
Fracture of skull. 
Death of child. 

Maternal exhaustion and prolonged convalescence. 

Premature rupture of the membranes not infrequently 
occurs from over-distention, when twins or hydram- 
nios is present, or at any stage of the pregnancy when 
the membranes are weak. The liquor amnii flows off, 



OBSTETRICS FOR NURSES 



not all at once, but after the first gush by intermittent 
discharges, depending on the painless uterine contrac- 
tions and the accuracy with which the head fits the 
pelvis. Labor usually comes on in from twelve to forty- 
eight hours, but it may be postponed for a month. 

The labor is sometimes more painful and prolonged 
on account of the absence of the fluid wedge and the 
generous lubrication of the channel which is supplied by 
the liquor amnii. 

The danger of infection of the amniotic cavity with con- 
sequent death of the child is always to be apprehended 
after the escape of the liquor amnii. Also the fcetal 
parts may prolapse and complicate the labor; or if the 
cord comes down, the child may be imperiled by its com- 
pression. 

If near term, the rupture of the membranes is not of 
great importance though the case must be watched atten- 
tively. Daily observation must be made of the foetal heart 
tones, the amount of liquor amnii flowing away, and 
the presence or absence of infection. If labor does 
not determine in a few days or if the heart tones rise 
above 160 or go below 120, labor must be inaugurated. 
(See Induction of Labor, p. 208.) 

Rupture of the uterus is the most serious accident that 
occurs in labor. It happens about once in three thou- 
sand confinements. The tear is usually in the lower 
part of the uterus and follows a prolonged period of 
labor, where the child is in a tranverse presentation, 
and, therefore, impossible to deliver, or the pelvis is 
too small or the child too large. It may also follow ill- 
advised or unskillful efforts to change the presentation 
by the introduction of the hand into the uterus. Occa- 
sionally rupture is produced by external violence, such 
as blows or kicks upon the abdomen. 



COMPLICATIONS IN LABOR 



227 



It is imperative to be able to recognize the symptoms 
when rupture impends or actually occurs. 

Signs of Threatened Rupture of Uterus. — 

1. High position of the contracting ring — especially its obliq- 
uity. The contracting ring is a ridge-like formation that 
may be found running across the anterior and lower por- 
tion of the uterus. 

2. High position of fundus. 

3. Tension of round ligaments. 

4. Eotation of uterus about its long axis. 

5. Tenderness to pressure of lower uterine segment. 
G. Contractions persistent with no pain-free interval. 

Signs of Actual Rupture of Uterus. — 

1. Haemorrhage is one of the earliest and most significant 
signs, and may be either external or internal. 

2. Cessation of uterine contractions either abruptly or 
gradually. 

3. Extreme pain felt by patient. 

4. Eecession of presenting part. 

The patient gives a sharp cry and has the feeling that 
something has given way. Signs of shock rapidly super- 
vene. A predisposition to rupture may be present from 
the scars of a Csesarean section, uterine tumors, and de- 
generation of the muscle. 

The treatment depends upon the degree of the injury, 
and if investigation shows that the uterus has opened 
into the abdominal cavity, immediate laparotomy is 
done. In other cases, the morcellation and removal of 
the child by the natural passage may permit the use 
of a uterine pack and avert the necessity for an abdo- 
minal operation. The child is usually dead and need 
not be considered. 



CHAPTER XV 



COMPLICATIONS IN LABOR (Cont'd) 

Vomiting" in labor frequently occurs near the end of 
the first stage. It is due to the sympathetic excitement 
of the nerves of the stomach as the last fibers of the 
os uteri give way. It requires no treatment. 

Hyperemesis in labor is very rare, but when it does 
occur, the delivery should be expedited. 

Haemorrhages may occur either before, during, or 
after labor. Haemorrhage is always serious. 

Haemorrhage before labor arises either from a pre- 
mature detachment of a normally implanted placenta 
or from placenta praevia. The first is sometimes called 
"accidental haemorrhage" to distinguish it from the 
latter, or "unavoidable haemorrhage." 

Accidental haemorrhage may be the result of an in- 
jury or a blow, but in many cases, there is no such his- 
tory. The haemorrhage is most frequent in the later 
months of pregnancy, and may be without any apparent 
cause. The haemorrhage may be entirely inside the 
uterus (concealed haemorrhage) or it may appear ex- 
ternally. 

The haemorrhage, when concealed, takes place back 
of the placenta or between the membranes and the 
uterine wall. If the haemorrhage is concealed, it is 
usually followed by an attempt to expel the child. If 
the haemorrhage is pronounced, systems of shock appear. 

The diagnosis is made by the symptoms which are 
summarized in differentiating this condition from 
placenta praevia (p. 231). 

228 



COMPLICATIONS IN LABOR 



229 



From this affection, nearly all the children and half 
the mothers die. 

When the haemorrhage is external and slight, the 
treatment may possibly be expectant for twelve hours, 
if carefully watched, but usually the symptoms become 
so serious that immediate emptying of the uterus is 
required either by the Vorhees bag, digital dilatation, 
version and extraction, or Cesarean section, the method 




Fig. 99. — Various forms of placenta praevia compared with normal attach- 
ment of the placenta. (American Text Book — Williams.) 

chosen being dependent upon the amount of the haemor- 
rhage, the vigor of the mother and the condition of the 
cervix, os, pelvis, and child. 

Placenta praevia is the name given to a placenta that 
is attached low down, in the uterus so that its margin 
or a large part of its mass overlies the os. This hap- 
pens through the action of the egg which embeds itself 



230 



OBSTETRICS FOR NURSES 



too far down on the endometrium — too close to t he 
cervix. 

Three different kinds are known and named from 
their manner of encroaching on the os, as marginal, 
partial, or central implantation of the placenta. 

The haemorrhage is from a loosening of the placental 
attachment owing to the stretching and growth of the 
uterus. 

There is only one symptom of placenta prcevia — sud- 
den, painless, causeless hemorrhage. The bleeding 
seldom appears before the twenty-eighth week, and no 
suspicion of a placenta praevia may arise before the ap- 
pearance of haemorrhage, which, as a rule, is soon re- 
peated. 

Labor frequently comes on prematurely and malpre- 
sentations naturally result from the inability of the pre- 
senting part to fit itself into the pelvis. 

There is no bag of waters, hence the first stage is* 
longer and bloodier and fraught with much danger. 

Interference is regularly indicated to save the life 
of the mother, while the child also has a high mortality. 
Puerperal infection is not uncommon. 

Placenta praevia is always an emergency. If the pa- 
tient can be kept under observation in a good hospital, 
one may temporize, but under other conditions the 
uterus must be emptied at once, even if only a single 
haemorrhage has developed. The indications are, (a) 
to control the bleeding, and (b) to empty the uterus. 
The life of the child must be disregarded and the mother 
alone considered. 

If the contractions have not begun, they should be 
stimulated by the introduction of a Vorhees bag, which, 
at the same time, dilates the canal and mechanically 
shuts off the bleeding vessels by compression. In in- 



COMPLICATIONS IX LABOR 



231 



troducing the bag, the membranes may be ruptured so 
the bag will pass into the uterine cavity. When the 
implantation is central, the finger must tear a hole 
through the placenta, and through this opening pass 
the bag inside the uterus. 

If the os is partially dilated, version may be done, 
and a foot brought down. The leg may then be pulled 
upon until it compresses the bleeding area and the 
traction maintained with a slowly developing pressure 
sufficient to check the haemorrhage, until dilatation is 
advanced enough for delivery. Occasionally good results 
are obtained by tightly packing the cervix and vagina 
with gauze or cotton. (See Vaginal Tampon, p. 204.) 

Cesarean section may be done in the interests of the 
child, as well as the mother. 

The foetal mortality in placenta praevia is said to be 
60 per cent and the maternal 10 per cent. 

Differential diagnosis between 
Accidental heemorrhage and Placenta prcevia 



Usually occurs in later months. 

May be concealed or open. 

Soon followed by labor pains. 

Uterus becomes larger if bleed- 
ing is concealed. 

Uterus hard and woodeny. 

In severe cases, signs of shock 
whether haemorrhage is ex- 
ternal or internal. 

No placenta can be felt. 

Haemorrhage continuous. 

No history of previous attack. 

No contractions after labor be- 
gins in serious cases. 
No bogginess of cervix. 



Any time after the twenty- 
eighth week. 
Always open and external. 
Labor need not occur. 
Uterus remains same size. 

Uterus, normal consistency. 

In severe cases, signs of shock 

follow the invariable external 

haemorrhage. 
Placenta can be felt through the 

os. 

Haemorrhage intermittent. 
Possibly history of previous at- 
tack. 

Contractions as usual. 
Cervix boggy. 



232 OBSTETRICS FOR NURSES 

Haemorrhages may occur during labor from retention 
of the major part of the placenta while a portion is 
detached. This may be due to pre-existent disease, such 
as endometritis, or from uterine inertia. 

Normally the placenta will separate and be discharged 
within an hour after labor and in the absence of haemor- 
rhage it may go even longer than this with safety. The 
occurrence of severe haemorrhage, however, requires the 
immediate cleaning out of the uterus by inserting the 
hand and peeling the placenta from its attachments. 

Post partum haemorrhage includes all haemorrhages 
that occur after the delivery of the placenta. 

The "flooding" as it is called by the laity, is most 
apt to come on either immediately or within an hour 
or so after labor. If it comes on after the first twenty- 
four hours, it is called secondary haemorrhage. Such 
predisposing causes as over-distention from twins may 
be present, but the haemorrhage may follow a perfectly 
easy and apparently normal labor so suddenly and so 
profusely that the woman may die in half an hour. 

There are four causes for post partum haemorrhage : 
namely, (a) uterine exhaustion (atonia uteri) ; (b) 
mechanical obstacles to retraction, such as clots or re- 
tention of pieces of placenta or membrane; (c) and 
lacerations of some part of genital passage, such as the 
vulva, vagina, cervix, or lower uterine segment ; and 
(d) the systemic condition known as haemophilia. 

"Bleeders" (haemophilias) are women whose blood 
lacks coagulability, owing to the absence of fibrin-pro- 
ducing elements. 

Post partum haemorrhage is usually an external 
haemorrhage, but the woman may bleed to death into 
her own uterus. 

Besides the external signs, the patient may show the 



COMPLICATIONS IN LABOR 



symptoms of acute anaemia, such as the rapid pulse, 
hurried, shallow respiration, pallor, cold sweat, yawn- 
ing, dizziness, etc. 

Nearly all these cases can be saved by prompt recog- 
nition and efficient treatment. 

The first step is to grasp the uterus. If the haemor- 
rhage is due to a tear low down, the uterus may be hard, 
but generally it is relaxed and requires vigorous mas- 
sage with both hands before it shows any signs of con- 
traction. In the absence of the doctor, the nurse must 
know how to undertake this maneuver. The uterus, 
after labor and especially when relaxed, is sometimes 
difficult to identify and the nurse can only make deep 
massage in the pelvis until the organ responds and its 
hard globular mass can be appreciated. As soon as the 
uterus contracts, clots and contained blood are expelled, 
and in many cases its bleeding ceases at once. (See 
Conduct of Third Stage, p. 149.) 

It may be necessary to keep the uterus contracted by 
manual massage in this way for several hours. As 
soon as possible, the nurse, or someone whom she 
directs, prepares a hypodermic of pituitrin — 10 to 15 Tt\. 
An injection of ergot may follow because its effect is 
more lasting than pituitrin. Next, a hot douche is made 
ready and the materials for packing the uterus are as- 
sembled. 

When the doctor arrives, he sterilizes his hands, puts 
on gloves and introduces two fingers or the whole hand 
into the uterus to remove clots or any retained frag- 
ments of placenta. 

The hot intrauterine douche may follow, and if Ike 
contraction is not firm and the haemorrhage checked, the 
uterus must be packed with gauze. If hemorrhage 
comes from cervix, it should be grasped with long for- 



234 



OBSTETRICS FOR NURSES 



ceps, pulled down, and sutured. It from perineum, 
pack first, and afterward sutures may be introduced. 

If the patient is exsanguinated, the foot of the bed is 
raised, coffee given by mouth, camphorated oil hypo- 
dermically, and normal saline transfused under the 
breasts. 

Pituitrin may be continued in larger doses. 1 c.c. 
will raise the blood pressure very definitely. Adrenalin 
also may be employed for this purpose. 

The following summary may be found convenient : 

Post Partum Haemorrhage 

Etiology, En notional. — 

Atony of the uterus, especially after rapid artificial or nat- 
ural emptying of the organ. 

More common after uterus has previously been greatly dis- 
tended. 

Premature version and extraction. 
Hydramnios and twins. 

Imperfect development of uterine musculature. 
Precipitate labors. 

Haste or improper management of third stage. 

Etiology, Mechanical. — 

Eetention of placenta — partial, total or solitary cotyledons. 
Inversion of the uterus. 
Placenta succenturiata. 
Inflammation of decidua serotina. 

Conduct of third stage, i.e., wait until placenta separates. 

Etiology, Systemic, Haemophilia. — 
Kind of haemorrhage. 

Haemorrhage before expulsion of placenta due to laceration of 
the soft parts, or 

Partial release of placenta and failure of uterus to con- 
tract, or 

Placenta may be attached to periphery or to one side. 
Attempts to expel placenta without waiting for uterine con- 
traction are sometimes productive of haemorrhage. 
Haemorrhage after expulsion of placenta. 

Haemorrhage in interval between pains — comes from pla- 
cental site. 



COMPLICATIONS IN LABOR 



235 



Haemorrhage in stream not checked by uterine contraction 

is due to laceration of the canal. 
Haemorrhage in abnormal quantities at beginning of pains. 
Pure atony — comes early. 
Haemophilia again. 

Diagnosis. — 

Palpation of uterus through abdomen. 

Placental site excluded from contraction (paralysis). 

View of vulva. 

Injuries. Plow continuous, fluid and bright red, shows ar- 
terial origin, probably from cervix. Examine. 
Atony — bleeding at intervals, clotted and dark. 
Haemorrhage from a tear begins at once. 

Uterus contracted and haemorrhage continues. Look for 
tear. 

If haemorrhage does not begin within ten or fifteen minutes 

after labor it is not from a tear. 
Always have haemophilia in mind. 

Management. — 

Third stage must be conducted properly. 
Before expulsion of placenta — early expression. 
Crede or manual removal — then secure contraction by mas- 
sage. 

Pituitrin, Ergot, or both. 

After Third Stage. — 

Eestore an inverted uterus. Eepair lacerations. See that 
cavity is clear and clean. 

Massage, intrauterine hot water douche, hand in uterus and 
hand outside and rub, ergot. 

Pituitrin hypodermically. Pack uterus with sterile gauze 
or weak iodoform gauze. Strict asepsis for all intra- 
uterine maneuvers. 
Treat anaemia with transfusion, elevation of foot of bed, coffee, 
external heat, hot rectal enemas, stimulation, bandaging of 
legs. 

Strychnine sulphate, adrenalin, or camphorated oil may be re- 
quired in usual dosage. 
Hypodermoclysis. (See Minor Operations, p. 206.) 

After the bleeding stops, the food must be most nu- 
tritious — milk, eggnog, rich soups, chicken and mutton 
broths, oyster stew, and beef steak as soon as she can 



236 OBSTETRICS FOR NURSES 




Fig. 100. — The knee-elbow posture. (Bumni.) 




Fig. 101. — The knee-chest posture. 



take it, A diet of fluids and stimulating foods that 
raise the blood pressure will most quickly relieve the 
symptoms. 

Eclampsia occurs in the last three months of preg- 
nancy as a rule, and most frequently just before or 
during labor, 



COMPLICATIONS IN LABOR 



237 



In about one sixth of the eases only, the attack may 
follow labor. The attack is characterized by violent 
convulsions, which come on with little or no warning 
unless the urine has been carefully watched. 




Fig. 103. — The improvised Trendelenburg position. (American Text Book.) 



The prodromal symptoms have already been de- 
scribed under albuminuria in pregnancy (p. 77). The 
marked features may be repeated for emphasis: per- 
sistent headaches, disorders of vision, spots before the 
eyes, blindness, edema of cheeks, eyelids, feet and hands, 



238 



OBSTETRICS FOR NURSES 



pain at the pit of the stomach, dizziness, nausea and 
vomiting and ringing in the ears. Suddenly the con- 
vulsion occurs, the facial muscles twitch, then the limbs 
and body are shaken by violent muscular spasms. The 
body becomes rigid, the tongue protrudes and the face 
is livid and cyanotic. The spasm usually lasts from one 
to five minutes and is succeeded by coma that lasts an 




Fig. 104. — The dorsal position with stirrups. (Dorland's Dictionary.) 

hour or more. In some instances there is no return to 
consciousness before the next attack, which comes on 
every hour or half hour, though occasionally only one 
seizure is noted. 

The blood pressure is greatly increased and the urine 
is diminished, the temperature rises to 101° or 102° F. 
When death ensues, it is most frequently due to edema 
of the lungs or cerebral haemorrhage. 

The greater the number of convulsions, the more se- 



COMPLICATIONS IN LABOR 



239 



rious the outlook as to life, and it is said that after 
twenty seizures fifty per cent of the mothers die. Un- 
der the best treatment approximately fifty per cent of 
the babies die. 




Fig. 105. — Dorsal position across the bed. (Bumm.) 



There is no routine treatment for eclampsia. 

The principles of management for the attack are (1) 
to empty the uterus, on the theory that the disease is 
a toxaemia of gestational origin, (2) to eliminate the 
poison, and (3) to control the convulsions. 



240 



OBSTETRICS FOR NURSES 



The albumin in the urine and other eclamptic symp- 
toms demand urgent attention in prophylaxis. 

For the pre-eclamptic period (see Albuminuria of 
Pregnancy, p. 77) a rigid milk diet is indicated. The 
bowels, kidneys, skin and blood vessels must all be 
brought into service. 

In the full blooded patient, venesection may be done 
and after drawing off ten or twelve ounces of blood, 
an equal amount of normal saline may be poured into 
the. same vein. 

Subcutaneous transfusion or the submammary intro- 




Fig. 106. — Flexed dorsal position with feet on the tahle. (American Text 

Book.) 

duetion of saline solution may be done. The skin is 
stimulated by hot wet packs and the bowels by saline 
cathartics and frequent irrigation of the colon. 

During the attack, the patient must be kept from 
injuring herself. A spoon wrapped in gauze or a small, 
long roller bandage should be slipped between the teeth 
to keep the tongue from injury. The clothing must 
be loosened or removed. No food, but only water is 
given by mouth, until the patient is conscious. 

The convulsions are controlled by morphine, chloral, 
or both. 



THE ABNORMAL PTJERPERIUM 



241 



Morphine sulphate, y± gr. is given hypodermically, 
followed in an hour by 30 gr. of chloral by mouth. Two 
hours later the morphine is repeated and six hours after 
the first dose of chloral, it is repeated. In this method 
(Stroganoff's), four doses of chloral and six of mor- 
phine are given in twenty-four hours. That is all. 
When the stomach will' not retain the chloral it may 
be given by rectum in milk. If a general anesthetic 
is used, it should not be chloroform, but ether. 

The labor, if begun, should be expedited by forceps, 




Fig. 107. — The Sims position. (Kelly.) 



or version and extraction. Bleeding during delivery 
should be looked upon as desirable. If "more rapid 
measures of delivery seem demanded and obstacles ex- 
ist, such as pelvic contraction, imperfect dilatation, or 
the prospect of a prolonged first stage, Cesarean sec- 
tion or forcible delivery (accouchment force) may be 
attempted. 

If the labor has not begun, when the convulsion oc- 
curs and a quick delivery by the normal passage does 
not seem feasible, then the Cesarean operation may be 
the best treatment. 



CHAPTER XVI 



THE ABNORMAL PUERPERIUM 

The practice of obstetrics has many features that are 
very gratifying to the nurse and physician. 

Instead of a surgical operation, which has come un- 
expectedly and undesired ; a disaster in which some part 
of the body is removed or altered by means of a proce- 
dure associated with extreme pain, mental tribulation 
and large expense, a much-wished for addition is 
brought to the family, with pain, to be sure, but a 
pain that is soon forgotten in the general joy. This is 
the normal condition that causes the nurse and the doc- 
tor to rejoice that such a delightful specialty has been 
chosen. 

Then comes a case in which the labor may be com- 
plicated by some dreadful anomaly, or the puerperium 
burdened or disordered by some unwelcome invasion 
that tortures the souls of the family and may cost the 
life of the mother, or child, or both. 

At such a time the nurse and the doctor feel the full 
weight of their responsibility, and after a series of 
anxious days and sleepless nights, they wonder why 
they did not choose gardening or a clerical position for 
their life work. 

The disorders of the puerperium are many and vari- 
ous, but naturally the breasts and the pelvic organs are 
most frequently affected. 

The breasts of the human female are not reservoirs 
of milk like the cow's, but a pair of highly sensitive 
organs that functionate and produce only as the de- 

242 



THE ABNORMAL PUERPERIUM 



243 



mand is made. It follows that when the milk comes in, 
the breasts become engorged and all the neighboring 
structures are involved in the new process. However, 
it is not milk that is overfilling the breasts, but serum, 
lymph and venous blood, which congest the tissues 
surrounding the glands and produce a hard painful 
mass. 

The breasts become heavy, hot, and painful; super- 
numerary glands in the axilla? enlarge, but there is 
no fever. There is but little more reason for a fever 
when the mammary gland begins to functionate than 
when the lungs fill for the first time except in the case 
of nervous patients who bear discomfort badly. 

If fever appears simultaneously with the milk, the 
cause must be sought in some atrium of infection, pos- 
sibly in the breasts, but usually elsewhere. There is 
no such thing as "milk fever." The enlarged glands, 
the tense mottled skin on which blue veins run visibly 
here and there, the nipple, flattened and drawn into 
the swelling, so that the child can not grasp it with the 
mouth, all produce a sense of disorder that ought to 
be associated with fever— but is not. This is the 
"caked breast" of the laity, and if let alone, the hyper- 
emia subsides and the function remains. The temper- 
ature in possibly two cases out of five may rise to 
100° F. for twenty-four hours, but it promptly sub- 
sides. These temperatures generally occur in neurotic 
women. 

If the breasts are irritated by binders, breast pumps, 
or massage, — like the blacksmith's arm, with exercise — 
the trouble, if not increased, is at least much slower 
in disappearing. 

It is reported that the young virgins of some African 



244 



OBSTETRICS FOR NURSES 



tribes nurse the babies in the family, the breasts being 
stimulated to produce milk largely by massage. 

If the condition of the breasts becomes too painful, 
the liquids by mouth are reduced to the last degree, 
saline cathartics are given until frequent watery stools 
result, one or more ice bags are applied to each breast 
and codeine sulphate may be given at night. The child 
nurses every four hours only. Williams was the first to 
show that no tight binder is necessary, but only a support- 
ing bandage. The tight binder is a cruel and useless bar- 
barism that has been abandoned by progressive physi- 
cians. No massage is allowed ; no pumps ; no irritation 
whatever, and in twenty-four hours the trouble has dis- 
appeared. Hot dressings to the breast are equally ar- 
chaic. They should never be applied to any breast unless 
it is desired to hasten suppuration. 

If the child dies, or for any reason can not nurse 
(inverted nipple, cleft palate, harelip) and it becomes 
necessary to dry up the milk, the treatment for "caked 
breast" is continued. After twenty-four hours the 
breasts are comfortable and rarely give trouble again. 

Cracks, Fissures and Abrasions of the Nipple. — The 
care of the nipples should be inaugurated about six 
weeks before labor, as elsewhere described : 

The nipple must be inspected and its possibilities 
determined, early in pregnancy, if possible, for many 
varieties of badly shaped and ill-developed nipples ex- 
ist which may make nursing difficult or impossible. 

Imperfect nipples especially are predisposed to fissure 
and crack, and will require extreme care on the part of 
the nurse. She should inspect them before and after 
each nursing and sedulously use cleanliness and asepsis 
in her management. In normal and tranquil as well 
as in neurotic women, the nipple may become so sore 



THE ABNORMAL PUERPERIUM 



245 



as absolutely to preclude nursing, and this entails 
much additional work on the nurse and mother, as 
well as considerable peril for the child. The condition 
usually begins as a fissure or crack, and is accompanied 
by much pain. It is serious, furthermore, in another 
aspect since all breaks in the surface of the nipple are 
avenues of infection that may result in mastitis. The 




Fig. 108. — Examples of imperfect nipples. (American Text Book.) 



child may produce fissures or abrasions by rubbing the 
nipple with his mouth, by pulling too hard, or by the 
habit of holding it in his mouth and macerating it 
with his gums when he has finished nursing. 

The child must not be left at the breast after he has 
nursed, but the nipple should be gently removed from 
the child's mouth by passing one finger in beside the 
nipple'. Fissures and abrasions usually occur within 
ten days if at all. Abrasions or erosions are due to 



240 



OBSTETRICS FOR NURSES 



the wearing away of th,e epithelial covering of the 
nipple in patches more or less extensive. 

Thin-skinned blonde women suffer more than those 
with dark, dense oily skins. 

A fissure is a distinct separation of tissue that goes 
deeply into the underlying substance. 

A crack is a long abrasion which may deepen into a 
fissure. 

Both fissure and crack may affect the top, the side 
of the apex, or the base of the nipple. They may be 
either longitudinal or circular. The entire nipple must 




Fig. 109. — A standard nipple shield. (American Text Book.) 

be kept under observation and the instant a raw sur- 
face is detected, treatment must begin. 

Compound tincture of benzoin, liberally applied, is 
a favorite and successful remedy. Our routine is to ap- 
ply a paste made of equal parts of castor oil and sub- 
nitrate of bismuth. This is put on after the child nurses, 
and must be removed carefully before the next nursing. 
Sometimes the child's stools become black and consti- 
pated and the trouble may be traced to imperfect re- 
moval of the bismuth preparation. 



THE ABNORMAL PUERPER1UM 



247 



Whatever medication is used, the nipple must be 
protected from injurious friction by the clothing. This 
is best done by the hat-shaped lead nipple shield, which 
is placed over the nipple and held in place by a light 
binder. The shield should be boiled before use. 

To protect the nipple during nursing, a glass shield 
may be used for a day or so, but not long enough for 
the babe to get accustomed to it, else he will form a 
habit hard to break. This shield must be taken apart 
after use, washed and kept in saturated solution of 
boric acid until the next nursing. 

If all these measures fail, the fissure must be touched 
with a nitrate of silver stick once, or have a 2 per cent 
solution of nitrate of silver applied night and morning. 
It may be necessary to take the child from the breast 
for a day or so, in which case he nurses the other 
breast and the side with the bad nipple is pumped. 

The care of the nipple is highly important since the 
apprehension and the actual pain of each nursing may 
prevent sleep, destroy the appetite, and diminish the 
milk. If begun early, most fissures will heal in twenty- 
four to forty-eight hours. 

Mastitis. — From three to five per cent of lying-in 
women have mastitis in the European clinics, but the 
records in America show a much smaller number. 

The disease occurs most frequently in blondes and 
in primiparas. It is most apt to appear during the 
first two weeks, when the congestion accompanying the 
new mammary function produces a stasis that favors the 
growth of germs, which may enter through the abrasion 
or fissures of the nipple produced by zealous activity of 
the child's gums. But it may also occur when the child's 
first teeth come and the nipple is again exposed to in- 



24,8 



OBSTETRICS FOR NURSES 



jury. At times it is impossible to find a plausible 
excuse for its occurrence. 

Mastitis is usually described in three forms: The 
(a) parenchymatous or glandular type, which affects 
the substance of the gland or the enveloping connective 
tissue; in (b) subcutaneous mastitis the connective tis- 
sue beneath the skin is attacked; and in (c) the sub- 
glandular variety, the infection finds a lodging between 
the gland and the chest wall. 

Mastitis is always due to the presence of micro- 
organisms which in many cases gain access to the gland 
through fissures or abrasions by means of the lym- 
phatics. In other instances the germs may be in the 
blood and a local stasis may encourage the infection. 
Still again, they seem to enter through the normal 
nipple openings. 

Symptoms. — The parenchymatous inflammation begins 
with a chill, and the temperature promptly rises to 102° 
to 105° F. The pulse is high. The patient complains of 
headache and thirst. Examination reveals hard, tender 
nodules in some part of the gland. The skin may or 
may not be reddened. 

If the trouble has begun in the connective tissue, 
the skin will be diffusely reddened, the nodule ill- 
defined, the temperature will rise gradually and the 
chill may be absent. 

Treatment. — The breast is put at rest. No tight 
binder is applied, no breast pump, no massage. No heat 
is allowable. 

Ice bags surround the gland night and day. The 
liquids by mouth are restricted and saline cathartics 
given. Codeine may be administered for pain. Usu- 
ally the symptoms subside without suppuration in from 
one to two days. 



THE ABNORMAL PUERPERIUM 



249 



Should the inflammation persist for more than two 
or three days, in most cases the tissue will break down 
and form a mammary abscess. When it is evident that 
suppuration has begun, heat may be applied to the 
gland and the process accelerated. The abscess may 
be superficial or deep and will be diagnosed by a bog- 
giness in a circumscribed area or by fluctuation. The 
abscess must be opened as soon as possible. 

The nurse sterilizes a bistoury and a pair of long 
artery forceps. Lysol solution and cotton sponges are 
made and sterile gauze for packing. The hands are 
surgically prepared and rubber gloves worn. If an 
anaesthetic is required, gas may be used, or chloroform. 
The incision is made radially from the nipple so as to 
minimize the injury to the milk ducts. A gauze drain 
may be required for a few days. 

In the after-care, the nurse must be scrupulously 
clean and not convey contagion from the breast to the 
woman's genitals, to the child's eyes, navel or vagina, 
nor to her own person. 

Excess of milk is rare, but may be observed for a 
short time after the glands fill. It seldom requires 
treatment, but saline cathartics, restriction of fluids, 
and putting the child on a four-hour schedule will 
reduce it. Pads may be worn if it runs away freely. . 

Scarcity of milk is only too common. There may be 
enough at first and the quantity gradually diminish, or 
it may be deficient from the very beginning. 

The faulty secretion may be due to the age of the 
mother, to disease (anaemia), to bad nutrition, or to 
overwork. It may folloAV a premature child. Com- 
pression of the breasts by corsets or tight dresses may 
prevent development. The amount of gland tissue is 
very important. Many women have large, fat breasts, 



250 



OBSTETRICS FOR NURSES 



but a small glandular development. Mental conditions, 
such as fright, worry, and anxiety, will diminish the 
flow of milk or stop it altogether. 

Symptoms— The child is fretful, goes to sleep after 
nursing but soon wakes up, or may nurse awhile, and 
then finding it useless, will cry and refuse the nipple. 
He loses weight and when weighed before and after 
feeding, the scales scarcely vary. No secretion or very 
little can be squeezed from the breasts. The child 
may be given a Bottle after which he goes to sleep. 

Treatment. — When the gland tissue is defective, no 
treatment can succeed. 

The appetite must be improved by bitter tonics and 
the mind relieved of its anxieties, if possible. Change 
of scenery may help. The fluids must be increased, 
milk, cocoa, chocolate and gruel must be pushed, and 
such vegetables added as corn and beets. Oyster 
stews, clams, lobsters, and crabs will help. The diet 
must be full and nutritious with especial stress on those 
foods that raise the blood pressure. Malt drinks or 
champagne may avail in some cases. Exercise in moder- 
ation is desirable. 

Artificial stimulation of the breast sometimes suc- 
ceeds. Massage will irritate the glands, increase the 
congestion, and promote functional activity ; or a Bier- 
vacuum apparatus may be put over the gland several 
times a day and the air pumped out, The breast should 
be kept distended for fifteen to twenty minutes. There 
is difficulty in this country in getting glass bells of 
sufficient size. 

Galactorrhea is the name applied to an abundant se- 
cretion of milk poor in quality toward the end of a 
long lactation or after the child is weaned. The symp- 



THE ABNORMAL PUERPERIUM 



251 



toms are an almost constant flow of milk with resultant 
anaemia. 

Treatment. — Elix. of iron, quinine and strychnine with 
compression of the gland. A dry diet and the avoidance 
of all irritation of the breasts will aid. 

To "dry up the milk," follow the treatment for 
"caked breast." 

Quality of the milk may be such that the child will- 
not take it or, if taken, it fails to nourish. In some 
cases this is due to overlong, or to irregular, periods 
between feedings; for when the nursing interval is too 




Fig. 110. — A standard breast pump. (American Text Book.) 

short, the milk becomes too rich, when too long, it 
becomes thinner and less nutritious. 

Fright, anxiety or anger may change the character 
of the milk so that colic, vomiting, and diarrhoea and 
indigestion are produced in the child. A wet nurse be- 
comes homesick and the milk dries up. It may become 
extremely indigestible, as shown in cases where a wet 
nurse quarrels with her husband and her foster child 
develops green stools. If the mother's milk does not 
agree, the child may be put on feedings for twenty- 
four or forty-eight hours, Avhile the milk, pumped from 
the breast, is sent to a laboratory for analysis. If a 



252 



OBSTETRICS FOR NURSES 



return to the breast is unsatisfactory, artificial feedings 
or a wet nurse must be supplied. 

Removal of the child from the breast may be re- 
quired for a variety of reasons. Thus, the mother's ad- 
diction to alcohol or opium is good ground for taking 
away the child. Arsenic, bromides and iodides of potas- 
sium, saline cathartics, salicylates, alcohol, opium and bel- 
ladonna must be given to the mother with great caution 
during lactation, for they pass over into the milk. 

Acute diseases, such as erysipelas, pneumonia, diph- 
theria, typhoid, malaria, pronounced puerperal sepsis 
or persistently high fever from any cause, usually dries 
up the milk ; while cardiac lesions, unless well compen- 
sated, chronic anaemia and tuberculosis, obviously de- 
mand the removal of the child for the sake of both. 
Sometimes a new conception, especially when the milk 
becomes poor in the last half of gestation, compels 
the mother to wean her babe. 

A syphilitic woman may nurse her own child, pro- 
vided her condition is good and the child also is syph- 
ilitic. 

Theoretically, the return of menstruation in no way 
affects the nursing child, unless the blood is lost to 
the point of anaemia. Yet cases do occur in which the 
child has indigestion, colic and bad stools, as well as 
loses weight, when the mother is menstruating. 

The quality of the milk is sometimes altered, but 
only for a day or so, and the child should continue at 
the breast unless some definite indication for removal 
arises. 

Weaning ordinarily is completed by the ninth month, 
but the child should never be carried beyond the twelfth 
month on account of changes in the character of the 
milk. 



THE ABNORMAL PUERPERIUM 



253 



When a child is weaned, the substitution of an arti- 
ficial food may be made gradually, — a bottle a day, 
two bottles a day, etc., until, in a couple of weeks, 
the breasts are at rest. 

The excessive prolongation of lactation is shown 
upon the mother by impairment of the health. The 
patient is pale, weak, anaemic, fretful, and thin. Head- 
aches, dizziness, loss of appetite, and constant fatigue 
will be complained of. 

The treatment is to remove the child at once and 
put the mother on stimulating drugs and foods. A 
change of air and scenery, if possible, will be highly 
beneficial. 

The wet nurse is always a tribulation, which must be 
endured until the child can be put on artificial food. 
She should have a Wassermann test before entering 
upon her duties. Syphilis, tuberculosis, and gonorrhoea 
must be guarded against. She must be kept like the 
family cow, in a placid frame of mind, fed on nutri- 
tious food that is not too rich, and exercised enough 
to keep the blood circulating. 

Light housework and duties that take her out of 
doors part of the time are advisable. Her moral char- 
acter can only be assured through those who have 
known her. If she brings her own child with her, she 
will need watching to provide for an equable distribu- 
tion of the milk. The first few days is never a criterion 
of a wet nurse's effectiveness. Change of food and 
surroundings may interfere with her usefulness. 

Gas may complicate the puerperium after Cassarean 
section, and even after normal labor. A rectal tube of 
soft rubber may be passed as high as possible into the 
bowel and left for some time, or enemas of S. S., tur- 



254 



OBSTETRICS FOR NURSES 



pentine, asafoetida, or milk and molasses may be given. 
By mouth calomel or mag. cit. is valuable. 

Headache in the puerperium should be watched care- 
fully, and the cause discovered. Pain in the head may 
be a habit with the patient, or it may be a symptom 
of some complication either present or developing, such 
as toxaemia, eclampsia, or acute yellow atrophy of the 
liver. In general, it is due to milder conditions like 
exhaustion, too many visitors, excitement, nerves, or 
insomnia. 

After-pains. — Sometimes patients are greatly annoyed 
by after-pains. The pain may be due to a clot retained 
in the uterus or possibly a stimulation of the uterus when 
the child goes to breast. Gentle massage of uterus, or 
ergot, quinine, or codeine may be required to bring 
about the expulsion of the clot or to control the pain. 
A reasonable degree of after-pain is of favorable sig- 
nificance. (See p. 154.) 



CHAPTER XVII 



INFECTION 

Puerperal fever is a wound infection. 

The conditions of the pelvic organs during labor and 
post partum, are well adapted to receive and develop 
microorganisms, for the healthy antimicrobic power of 
the vaginal secretion is absent or diminished. 

A long and exhausting labor, possibly accompanied 
by haemorrhage, or terminated by an operation, has 
diminished the immunity and broken the resistance of 
the tissues to a dangerous degree. 

The mucous membrane of vulva and vagina are torn 
and bruised, the vitality lowered, and the surface cov- 
ered with bloody lochia, which is an excellent nutri- 
tive medium for microbic development. The uterus is 
a vast, open wound, filled with fibrin, blood clot, and 
decomposing tissue, while the whole pelvis is main- 
tained at exactly the proper temperature for germ 
propagation. 

Through these wounds, toxins are carried into the 
circulation, and germs, nourished upon the abundant 
and favorable culture media, pass through the uterine 
walls or by way of the lymph channels first into the 
adjacent tissues and thence to all parts of the body. 

Certain definite organisms reach the disintegrating 
tissues and produce a putrefaction. They do not, how- 
ever, once their work is done, pass into the body. But 
in producing putrefaction, they also produce injurious 
poisons, called toxins, which do enter the body and 
cause an absorbtive fever known as sapiwmia. 

255 



256 



OBSTETRICS FOR NURSES 









\t ' 


'A V f? 

• i 




. >>,.V &\ 1 




A* 


, S 






i , 

' i 




v ''>«••'/ . ** a» 

* * w ^ -• * 
... ^4? »\ 

;: T ; i * '5 
# *! 


• 


V * ' 

c - I 



Fig. 111. — Germs most frequently found in cases of puerperal fever. 
(Kellv's Gynecology.) 1, streptococci (in chains); 2, gonococci; 3, tubercle 
bacilli (not a source of puerperal infection) ; 4, bacillus coli communis ; 
5, staphylococcus pyogenes aureus ; 6, bacillus aerogenes capsulatus. 



INFECTION' 



257 



Other organisms are the pus microbes, which begin 
their growth in any favorable location and continue 
to spread and nourish onward and inward by blood 
vessel, tissue or lymphatic, until overpowered by the 
resistances of the body, or until by general sepsis, they 
have killed the patient. These are the streptococcus, 
staphylococcus, bacillus coli and bacillus pyocyaneus. 
These are the germs that the nurse or the doctor may 
bring to the patient on hands, clothing, or hair. These 
are the organisms against which our scrupulous asepsis 
and antisepsis is directed. It is against them and their 
activities that the doctor and nurse prepare by the 
long and painful scrubbing of the hands and elbows, 
the rubber gloves, by the shaving and scrubbing of the 
patient, and by all the paraphernalia and equipment that 
go to furnish the modern lying-in- chamber or delivery 
room. It is on account of these germs that the con- 
scientious doctor or nurse lies awake nights and pain- 
fully reviews his technic when his patient has a temper- 
ature; and it is on their account that he shudders at the 
callous disregard of human life that is shown by those 
Avho do not observe the known laws of asepsis. 

It is true that many women escape when the attend- 
ant is unclean, but this is due to a splendid immunity, 
and in no way absolves the man or woman who neglects 
his asepsis and has patient after patient running tem- 
peratures, some of whom are bound to die or be crip- 
pled for life. It is for this reason that a surgeon should 
do surgery and not general practice ; it is for this rea- 
son that an obstetrician should limit himself to the 
care of women in childbirth and not endanger them by 
taking cases of scarlet fever, erysipelas, and unclean 
surgery. 

In country practice, all kinds of work must be done 

,i 



258 



OBSTETRICS FOR NURSES 



since there are not enough men to specialize, but it is 
inexcusable in the city where a man can always be 
clean and keep clean, if he is willing to forego the in- 
come derived from attendance upon septic and infec- 
tious cases. Any article not surgically clean may 
contaminate the patient by contact ; but ulcers, sup- 
purating wounds, abscesses, and hands improperly or 
insufficiently cleaned are the deadliest causes of post 
partum temperature. 

Infections are said to be either self-produced or 
brought to the patient from without. 

The only organism that is demonstrably self-infec- 
tious is the gonococcus, which may be present in the 
vagina before labor and may infect the puerperal woman ; 
but it is wiser, safer, and more nearly accords with 
the facts, to regard all infections as alien borne, as 
brought to the patient and introduced by the unclean 
hands or instruments of her medical attendants. 

Prevention. — A conscientious and capable nurse, or 
doctor will not go from an infected case to a confine- 
ment. Both will keep their bodies clean, the teeth 
filled, and pyorrhoeas scraped and treated. The occur- 
rence of pus anywhere on the body is sufficient reason 
for the doctor to give up his confinements for a time, 
and the nurse to report off duty. 

No raw, and but few mucous surfaces should be 
touched by the fingers of the attendants, where a ster- 
ile instrument can be used. 

The nurse should never make vaginal examinations 
unless an emergency exists, and then only when her 
instruction has been thorough and her experience great. 
Every examination is a possible source of danger, no 
matter how carefully the hands and patient are pre- 
pared. The nurse is not to change the pads without 



AC 



INFECTION 



259 



washing her hands, and she must wash her hands al- 
ways after changing the pads, before dressing the 
navel of the child. 

The navel or eyes of the child may be infected easily 
by the hands of nurse, doctor, or patient. The breasts 
of the mother may be infected by the hands of nurse, 
doctor or patient. The vulva and vagina of the puer- 
peral woman is highly susceptible to infection from the 
hands of nurse, doctor or patient. 

Ride. — All temperatures arising in the puerperium are 
due to infection, unless satisfactorily explained by find- 
ing the source. The possibility of a slightly elevated 
temperature from insignificant causes may be kept in 
mind, but such temperatures are transient and yield 
quickly to appropriate treatment or to none at all. 

Puerperal infection is most apt to appear during the 
first week of the lying-in period, and it generally de- 
velops about the third or fourth day post partum. If 
the symptoms come on later than this, there is always 
a hope that the infection has taken its origin in some- 
thing else than the labor. 

Symptoms. — In mild cases, a rapid pulse, headache, 
and a temperature of 101° or 102° F. may be the only 
symptoms. Severe cases begin with a chill, followed by 
a marked rise of temperature. The temperature is al- 
ways irregular and generally remittent. 

The pulse rises to 120 or 130 beats a minute, headache 
and prostration appear, occasionally associated with 
vomiting. 

The flow of lochia may be either increased or dimin- 
ished and either offensive or free from odor. Foul- 
smelling lochia is a sign of putrefaction but not nec- 
essarily of sepsis. 

At the same time there is some tenderness in the 



260 



OBSTETRICS FOR NURSES 



lower part of the abdomen, usually most marked at 
the sides of the uterus. The uterus is larger than it 
should be, and not hard, but doughy and sensitive to 
touch. 

The involution is arrested, except in cases of pure 
septicaemia. This is an important reason for the daily 
observation and recording of the regular descent of the 
organ. 

The disease runs a variable and more or less pro- 
longed course and the prognosis is always doubtful un- 
til the event. Signs of grave import are : repeated 
chills, insomnia, pulse above 120, persistent vomiting 
and meteorism, Avith dry, brown tongue. 

Treatment. — Mild cases without chill when the uterus 
is large and the lochia sometimes offensive, are usually 
sapraemic. Free catharsis, ergot in full doses, and a 
half sitting position to aid drainage will cause the 
symptoms to subside in two or three days. 

In the severe type, the treatment is mostly a case for 
careful nursing. The more energetically the doctor 
acts, the more liable he is to do harm. The patient 
needs all her strength to fight the disease, and should 
not be required to fight the consequences of injudicious 
interference. 

There is still some discussion about the advisability 
of assuring oneself that the uterus contains no remnants 
of the labor. Some feel that this should be determined 
by curetting the uterus with finger or instrument and 
following the operation with an intrauterine douche. 
If this is the view of the attending man, the nurse must 
aid, for the responsibility is his and not hers. 

On the other hand, the weight of authority at pres- 
ent seems inclined to the view that any remnanl of the 
labor Avill drain out naturally or be expelled by ergot- 



INFECTION 



261 



driven contractions without the necessity of opening 
up new raw surfaces by interference and. thus spread- 
ing the infection. 

The main idea is to promote drainage in every way 
possible. No curette, no douche, no uterine packing. 
Nevertheless, the vulva may be cleansed and the vagina 
carefully retracted and by appropriate means a culture 
obtained from the uterus. If this shows streptococci, all 
local treatment is to be abandoned at once. 

In general, the food must be fluid, and as nutritious 
as possible. This means milk, beef and mutton broths, 
oyster stew, etc. The nourishment must be pushed art- 
fully and ingeniously. Alcohol is not indicated. The 
bowels are kept open. 

Normal saline, drop method, by rectum, will pro- 
mote diuresis, skin action, and supply the body with the 
much needed fluid. Subinvolution is controlled by er- 
got in full doses. The room must be light and as many 
windows opened as the weather will permit. Frequent 
change of posture, from side to side, from dorsal to 
prone and especially to the half-sitting position, will 
li'ive the patient comfort and prevent decubitus (bed 
sores). The daily bath with an alcohol rub, keeps the 
skin in good condition and eases the mind. 

The child should be taken from the breast, because 
the milk is poor in quality and quantity and it may 
be infectious. Besides, the mother needs all her 
strength. Nature usually solves the problem by dry- 
ing up the milk. 

All pads soiled by the patient should be collected 
in paper bags or rolled in newspapers and burned. 
Sheets, towels, and pillow slips must be boiled in the 
house and not sent to the laundry. They should be 
soaked for half a day in a 2 per cent solution of lysol 



262 



OBSTETRICS FOR NURSES 



before being washed, and exposed to the hot sun for 
a day or so afterward, if possible. No comforts should 
be used on the bed, and the blankets must be left sus- 
pended in the room when it is fumigated at the con- 
clusion of the case. All dishes and utensils can be 
boiled. Plenty of air and sunshine are essential for 
the cure of the patient and to prevent the spread of 
the disease. 

The nurse must use every precaution to avoid carry- 
ing the infection to herself or others. Rubber gloves 
should be worn while changing the dressing. It is bet- 
ter to have the child cared for by another nurse. The 
nurse must get her rest and some exercise out of doors 
every day. It rejuvenates her and reacts to inspire the 
patient. 

When she leaves the case the nurse should boil her 
linen and wash her hair with soapsuds and hot water, 
and bathe frequently. 

Milk Leg. — This is an infection characterized by 
swelling of one, or rarely, both, limbs, from the foot 
to the groin. The leg is white from the edema, and 
as the condition is associated with fever and since 
the milk diminishes or disappears about the same time, 
it was thought in former days that the milk went to 
the leg. 

The cause of the swelling is a phlebitis of the exler- 
nal iliac or femoral vein which becomes thrombosed 
or so filled with clots that the return circulation is 
impeded. 

Symptoms. — The attack is signalized by a rise of tem- 
perature to 102° to 104° F. There is headache, pain in 
the affected limb, and general prostration. It is a true 
sepsis. 

The disease appears usually in the latter part of the 



INFECTION 



263 



second week of puerperrum, when the patient has be- 
gun to congratulate herself that all danger is over. 
In many cases the doctor has yielded to importunity 
and let the patient get up before involution was suf- 
ficiently advanced and the patient will report that she 
got up too early. 

The limb must be immobilized and kept warm. The 
immobility should be maintained for at least ten days 
after the fever has subsided and the pain gone. 

The convalescence may be protracted over weeks and 
months. 

Bed sores may complicate a long convalescence. Bath- 
ing with alcohol or alcohol and alum, and the frequent 
change of the patient's position will usually prevent 
them. Rubber rings and sheeting should not be used if 
it can be avoided. Ointments containing zinc are of 
great value in the cure of this affection. 

Phlebitis, in minor degree or in localized sections, 
may occur in the veins of the leg and the site of the 
invasion will be outlined as red lines or as irregular 
nodules. Some fever may attend the condition. Rest 
of the affected member, with ice bags for the pain, con- 
stitute the treatment. Bed sores must be guarded 
against. 

Sudden death in the puerperium is a shocking dis- 
aster. Rapid death may follow the complications of 
labor accompanied by haemorrhage, such as placenta 
praevia, rupture of the uterus, etc.; but death may be 
sudden, without warning, from pulmonary embolism, 
acute myocarditis, fatty degeneration of the heart, or 
the entrance of air into the uterine veins. This may 
happen several days after labor in a woman who is 
passing through a convalescence apparently normal in 
every respect. Such an event is probably due to a 
thrombus which may form in any of the veins of the 



264 



OBSTETRICS FOR NURSES 



body, but more frequently in those of the pelvis and 
legs. In the latter it may be recognized by hard Lumps 
that form somewhere along the course of the veins in 
consequence of a phlebitis. There is always the men- 
ace that some fragment of this mass, which is merely 
a hard clot of blood, may become detached and float 
off in the circulation to other parts of the body, such 
as heart, lungs, or brain (embolism), and by inter- 
ference with those structures, produce paralysis or in- 
stant death. When a thrombus is diagnosed, the af- 
fected part must be kept as quiet as possible. No 
massage is permissible. Tincture of iodine or 20 per 
cent ichthyol may be applied. The woman should re- 
main quiet for at least ten days after the apparent 
disappearance of the symptoms. 



THE CAKE OF THE CHILD 

Hitherto the mother and the complications and 
changes peculiar to her condition have been selectively 
considered, to the neglect of the child; but the labor 
being over, and the nurse having assured herself that 
the uterus is hard, that there is no hemorrhage, and 
that the mother is resting, now turns to the child ly- 
ing in its blanket. A hot water bag, carefully tested, 
should lie at its feet wrapped in toweling or napkins. 

The eyes have already received the Crede treatment, 
1 per cent solution of silver nitrate or possibly a 15 
per cent solution of argyrol for prevention of ophthal- 
mia, and a thorough cleansing comes next. 

In a warm room, away from drafts, the nurse takes 
the child in her lap, or on a table, with a blanket under- 
neath. She first anoints the child all over, either with 
benzoated lard, liquid albolene, sterile vaseline, or ol- 
ive oil. This softens the vernix caseosa that covers the 
child and aids its removal. 

The skin is wiped carefully with cotton or a soft 
cloth, paying particular attention to the folds of the 
groin, the arm pits, and the genitals. The nostrils are 
gently wiped out with applicators dipped in oil. 

The child must be covered as much as possible dur- 
ing the operation and the work finished quickly. The 
whole period should not exceed twenty minutes. 

During the cleansing process the nurse should look 
closely for anomalies or anatomical imperfections, like an 
imperforate anus or urethra, supernumerary digits, etc. 

265 



266 



OBSTETRICS FOR NURSES 



The Bath.— Daily, until the cord conies off, the baby 
is sponged with oiled pledgets, followed by a spray 
bath, or a sponging with lukewarm water and castile 
soap. The child must not be put into a full bath tub 
on account of danger of infecting the umbilicus. The 
bath water in a tub or basin quickly becomes filled 



'i A, ^2 


J — > 


V 


PI IX 


i i 


In 

• J JT 
.. / 1 




m- 'sT 





Fig. 112.— Rubber bath tub. 



with bacteria from the surface of the child's body and 
may be conveyed quite easily to a raw wound. 

All discharges must be wiped away, and the buttocks 
cleansed with oil. If the skin becomes irritated by 
urine or otherwise, the child should be well covered 
with talcum powder, especially in the folds of the groin 



CARE OF THE CHILD 



267 



and in the genital crease. All infants are benefited by 
a little mild massage after the bath. 

If other babies are handled, a child with infected 
eyes, or skin eruptions, must be quarantined and cared 
for separately by a special nurse. The color of the skin 
should be pink, changing under manipulation to red. 
If there is mucus in the mouth, it may be wiped out 
with an applicator, if in the throat, the child may be 
held up by the feet and the head drawn back for a few 
minutes so that gravity will aid the discharge of the 
obstruction. 

After cleansing the skin, the nurse sterilizes her 
hands and dresses the cord. The gauze which was 
temporarily wrapped around the stump is removed, the 
cord and adjacent skin washed with alcohol and dried. 
The stump is powdered above and at the sides with a 
mixture of equal parts of boric acid and subnitrate of 
bismuth, and then wrapped in gauze. The band is put 
on, the temperature taken, and the baby dressed. Some 
physicians prefer to have the cord dressed in 95 per 
cent alcohol, which is frequently renewed. The normal 
separation of the cord takes place through a kind of 
dry gangrene, which should be favored by dry rather 
than wet dressings. The 95 per cent alcohol does not 
remain at 95 per cent after it is exposed to air, hence 
it does not absorb moisture from the cord as absolute 
alcohol would. However, the attending man is respon- 
sible, and his orders must be followed. 

The Umbilicus. — The cord may be severed as soon 
as the child has cried lustily or the cessation of pulsa- 
tion may be awaited, in either case the child secures 
a little more blood, which gives him a better start in 
life. 

Two tapes are tied about the cord, one close to the 



268 



OBSTETRICS FOB NURSES 



skin margin of the child and the cord is cut between 
them. A kind of mummification or dry gangrene nor- 
mally develops and the stump falls off, as a rule, about 
the fifth day, leaving a moist, granulating area, which 
forms the umbilicus. 

A metal clamp may be used in place of a tape to com- 
press the cord. The advantage of the clamp is that 
on account of its greater width and rigidity it does 
not cut through the cord when applied. Furthermore, 
it can be made and kept more nearly aseptic. It does 
not soak up the juices from the cord and form a culture 
medium for germs. It can be removed on second day. 




Fig. 113. — The Pettit cord clamp. 



The cord usually comes off a day or so sooner than when 
the tape is used. 

The care of the cord is extremely important, as many 
infections can be transmitted through it to the child. 
At each dressing the cord is inspected, and whether it 
is dry or moist, offensive or inodorous, should be noted. 
These facts, with the falling off of the cord, are put 
down on the history sheet as they are observed. The 
binder, after each removal, is not pinned, but sewed 
on. The sewing should begin below and go up in or- 
der to have the tightness low down. 

Eyes.— After the first instillation of silver nitrate so- 



CARE OF THE CHILD 



269 



lution, a reaction appears with redness, swelling, and 
discharge, which passes off without treatment in two 
or three days. During the hath, care must he used not 
to get anything into the eyes nor anything from the 
eyes or nose upon the navel. 

At each dressing the nurse should irrigate the edges 
of the lids gently with boric acid solution. If the eyes 
become red, swollen, and have a purulent discharge 
after the second day, the case is possibly ophthalmia 
and they must be watched with extreme vigilance. A 
smear should be taken for the microscope and prepa- 
rations made for energetic treatment. 

The following summary may be of service in memo- 
rizing the routine of nursery procedure. 

Nursery Rules 

1. Keep temperature of nursery 68° to 72° F. 

2. During bath, keep temperature of nursery 75° to 80° F. 

3. Temperature of bath water 98° to 99° F. 

4. Never use a diaper that has not been laundered. 

5. Tie case number on child's arm before leaving delivery 
room. 

6. Watch cord for haemorrhage. 

7. Record temperature, stools and mine. 

8. Give water freely between feedings. 

9. Put to breast twelve hours after birth, and every three 
hours thereafter until the child begins to gain, then 
one and possibly (?) two night feedings may be omitted. 

10. Change binder daily. 

11. Oil bath first, then shower bath on subsequent days. 

12. Dress cord with alcohol 95 per cent, dry and apply bismuth 
subnitrate and boric acid powder (equal parts) into 
crevices beneath clamp or tape and under edges of the 
crust. Change dressing daily. Cord should fall off 
fifth day. Report failure to do so. 

13. Clamp may be removed on second day. 



270 



OBSTETRICS FOR NURSES 



Routine for the Child. — 

1. Temperature. 

2. Undress. 

3. Weight. 

4. Shower bath. 

5. Dress cord — record condition. 

(5. Binder daily until discharged. 

7. Diaper and dress. 

8. Sponge eyes with boric solution. 

9. Cleanse nostrils with albolene. 

10. Brush hair. 

11. Drink of warm water. 

12. Observe case number daily. 

Clothing.— (See Infant's Outfit, p. 101.) The cloth- 
ing must be light, loose, warm, and not irritating to 
the skin. The outside garment should have wing sleeves 
which permit free motion of the hands, but do not per- 
mit them to reach the eyes. 

The band of plain outing flannel should always be 
Avorn for the first few weeks. 

Birds-eye linen makes the best diapers on account of 
its superior absorbent qualities. 

The feet must be kept warm by stockings, and arti- 
ficial heat, if necessary. On hot days much of the 
clothing may be removed and the shirt, band and dia- 
per may be all that are needed. 

The care of the shirts and bands is part of the daily 
duty of the nurse. They must be washed daily, either 
by the nurse herself or under her supervision, as they 
are easily injured. After washing, in soft water, if 
possible, and with wool soap, they must be dried on a 
stretcher. Diapers must be put directly into cold water. 
Faeces may be brushed off with a whisk broom, and the 
napkin rinsed, boiled and again rinsed. No diaper 
should be used a second time until this has been done. 
No bluing may be used on the diapers and the soap 



CARE OF THE CHILD 



271 



must be mild, otherwise chafing and intertrigo will 
follow. 

The infant's toilet basket must contain: 

4 soft bath towels. 

1 pound of absorbent cotton. 

1 dozen wash cloths of soft material. 

1 small hair brush. 

1 pair nail scissors. 

Talcum powder. 

Bath thermometer. 

Hot water bottle. 

Albolene. 

Castile soap. 

8 oz. boric acid solution. 

8 oz. benzoated lard. 

Paper bags for waste. 

Pitchers and basins. 




A B C D E 



Fig. 114. — A, standard breast pump; B, standard nursing bottle; C, the 
breast tray; D, the Wansbrough lead nipple shield; H, the Brophy nipple 
for harelip and cleft palate. 

Weight. — The weighing of the child should precede, 
for convenience, the first cleaning of the skin and the 
daily bath. The child is either put on the scale naked 
or weighed in a blanket, and the weight of the blanket, 



272 



OBSTETRICS FOB NURSES 



ascertained before or after, is subtracted. The daily 
weight record is just as important as the temperature. 
A scale that registers ounces and fractions thereof 
mus1 be used, and the child should be guarded from 
falling during the performance. Usually the child loses 
from eight ounces to a pound the first week, but it 
should gain back to its birth weight, by the end of the 
second week. If the child does not gain, it may be due 
to lack of milk from the breast, and the weight may 
be taken before and after feeding to verify or refute 
the suspicion. 

The mouth should be inspected each morning, but 
not cleansed with the boric acid solution unless def- 
initely indicated. Spots or any unusual appearance 
should be reported. 

The Genitals. — The vulva of the female infant usu- 
ally requires but little care besides cleanliness. There 
is sometimes a whitish discharge w hich disappears spon- 
taneously in a few days. It is a drainage of vernix, 
smegma and epithelium from the vagina and labia. 

With a male, the prepuce must, be inspected when 
the child is about a week old. If it is long and the 
orifice small, circumcision may be suggested! Under 
any circumstances, the foreskin must be retracted, the 
adhesions broken up, and the smegma removed. This 
must be repeated daily until the adhesions do not re- 
cur. The maneuver should be done the first few times 
by the physician, for fear of a paraphimosis. 

Sleep in the newborn is normally quite deep and al- 
most continuous, probably twenty-two hours a day, for 
the first week. The rather fast respiration of the child, 
even when sleeping, is no cause for alarm. A healthy 
infant breathes about twenty-five times a minute. The 
child should not be rocked, carried about, exhibited, or 



CARE OF THE CHILD 



273 



handled more than necessary. It should not sleep with 
the mother, lest it become too hot or too cold, he over- 
whelmed by bedding, or overlaid by the mother. 

Bowels. — The first stools are black and tar-like, — this 
is meconium. It disappears by the end of the firsl 
week. The presence or absence and the character of 
an evacuation, as well as the number in twenty-four 
hours, must be daily recorded. For a breast-fed child, 
there should be three or four a day, for the first ten 
days and the number should gradually diminish until 
a routine of two a day is obtained. 

The diaper of bird's-eye linen should be large and 
thick ; two may be used if required. They should be 
carefully washed after soiling. Bluing must not be 
used, because where this substance comes in contact 
with the skin, irritation follows. 

Weaning- should be brought about by the gradual 
substitution of other foods, somewhere between the 
sixth and twelfth months. 

Urination should be copious. The child is always 
wet, and frequent changes are necessary to keep the 
skin from getting raw and sore. 

Both bowels and bladder should be emptied within 
the first twenty-four hours. Failure to do so should he 
reported, as an imperforate anus or urethra may exist. 

Frequently a piece of ice whittled out like a lead 
pencil and passed into the rectum will stimulate urina- 
tion. 

Catheterization is practically never necessary. The 
child may go three days without injury, but the con- 
dition of the bladder above the pubes must be atten- 
tively watched and its degree of fullness appreciated 
by percussion. 

Nursing. — The child should be put to the breast 



274 



OBSTETRICS FOR NURSES 



twelve hours after birth and every three hours there- 
after — no more and no less without definite reasons. 

If the child is strong and vigorous, only one feeding 
may be given at night, and even this may be omitted in 
some eases where the child gets an abundance of food. 
Six or seven feedings a day are enough. The child 
should stay at the breast from fifteen to twenty min- 
utes, depending on its activity and the rapidity of the 




Fig. 11S. — Proper position of mother while nursing child. (Witkowski.) 



milk flow, and then be removed. It must not be per- 
mitted to sleep at the breast. 

Care must be used that the child gets the nipple over 
the tongue and not under it. Many infants have to be 
taught to nurse. This may be due to a lack of strong 
animal instinct in many cases. There may be an abun- 
dance of milk and a good nipple, but the child will not 
learn to nurse without a vast expenditure of time, pa- 
tience, and energy on the part of the nurse. Squeezing 
a little milk into the mouth or filling a nipple shield 



CARE OF THE CHILD 



275 



with milk will sometimes aid in educating the infant, 
or even starting the supply with a pump, as many 
nurses do, is advantageous. Certain drugs, like castor 
oil and turpentine, taken by the mother, may affect the 
taste of the milk, and be reason enough for the refusal 
of the child to take hold. Other drugs like mercury, 
arsenic, potassium iodide, and alcohol may go over in the 
milk to the nursing child. 

If the child is weak or premature, the milk must be 
pumped from the breast and fed to it until strength 
comes. The difficulty about this is the bad habit ac- 
quired, but there is no way to avoid it. 

A child should get at each feeding half an ounce of 
milk to each pound of weight. The capacity of the 
stomach at various months is given by Hirst as, first 
week, 1/2 oz. ; second week, 2 1/2 oz. ; third and fourth 
week, 3 oz. ; third month, 5 oz. ; fifth month, 9 oz.; ninth 
month, 12 1/2 oz. Holt says that the capacity at birth 
should be one ounce, and increase at the rate of an 
ounce a month up to the sixth month. 

As hunger stimulates the gastric and salivary glands, 
so the sight of the child arouses some emotional cen- 
ter in the mother, which starts the milk, and the mouth 
of the child provides an additional stimulus of great 
power. About fourteen ounces is secreted by the sev- 
enth day, and after the second month the daily average 
rises to three or four pints. Milk secretion is favored by 
drugs and foods that raise the blood pressure and di- 
minished by substances that lower the blood pressure. 

There may be too little milk in the breasts, and if so, 
the child will lose weight daily; also the child will 
waken before nursing time, fret, refuse water, but 
greedily seize the nipple if it is presented. It will con- 
tinue to nurse long after its time is up and cling and 



276 



OBSTETRICS FOR NURSES 



cry when removed. The breast itself may seem flabby 
and loose, and no milk, or very little, can be pressed 
from the nipple. 

Normally, the breasts feel full and tense, both to pa- 
tient and nurse, just before feeding time. The real 
lest, however, is in taking the weight of the child be- 
fore and after feeding. Where the milk is insufficient, 
the scales will not vary, and after a few repetitions the 
nurse can be certain. An infant should be handled as 



f 




Fig. 116, — Proper method of taking rectal temperature. 

little as possible after feeding lest the milk be vomited. 

Temperature of the newborn child varies from 98° to 
99° F. It should be taken morning and evening, or 
oftener, if complications are suspected. 

The temperature often goes up on the third or fourth 
day, and may stay up for several days. This phenom- 
enon is called by some a starvation or inanimation fever. 
The temperature may go to 106° P. and the rise is gen- 
erally associated with a hot dry skin, dry lips, weak 



CARE OF THE CHILD 



277 



pulse, restlessness, and great prostration. The fon- 
tanelle may be sunken and the cry sinks to a fretful, 
feeble whine. 

It is important that the fever should be recognized and 
treated, since the condition may terminate fatally. The 
etiology is obscure. The fever should not be confounded 
with pyogenic infect ions, for these rarely begin before the 
fifth or sixth day. 

The treatment is simple. Give Mater regularly every 
two hours by month, and rectal flushings of normal sa- 
line tAvice daily. The symptoms rapidly subside if the 
child is properly nourished. Hence the breasts should be 
inspected and the child Aveighed before and after feed- 
ing. Usually the milk is poor and scanty. If the tem- 
perature does not soon fall the child should be put to an- 
other breast or artificial feedings should be instituted. 



CHAPTER XIX 



THE CARE OF THE CHILD (Cont'd) 

Heart. — The heart tones while in the uterus may vary 
between 138 and 150 per minute, but when higher than 
160 or lower than 120, danger is near. After delivery, 
the heart runs from 130 to 140, and during the first 
year gradually drops to 115, approximately. 

Asphyxia neonatorum is a condition, wherein, for 
some reason, the child fails to breathe after delivery. 
Out of every one hundred babies born, about six will 
die at birth or within the first ten days, and a large 
proportion of them from asphyxia in some form. 

Asphyxia is found in two degrees: asphyxia livida 
(blue) and asphyxia pallida (white). 

In the first, the child is deeply cyanosed. This may 
be due to patency of the foramen ovale, and yet it is 
a question whether this cyanosis is not really a normal 
process. The child does not undertake its first respira- 
tion because it needs oxygen, but because an excess of 
carbon dioxide (C0 2 ) in the blood acts as a stimulant 
to the respiratory center, which is thus set to work, 
with the result that oxygen is taken in. The blue 
asphyxias, therefore, may be only the first step in the 
physiological process of respiration. In these cases, 
the pulse is strong and full, and the muscular tone is 
preserved, as well as the sensibility of the skin. 

In the second degree, the condition is quite different. 
The face is pale though the lips may be blue. The 
heart is irregular and many times can not be felt. 
The cord is soft and flaccid, with its vessels nearly 

278 



CARE OF THE CHILD 



279 



empty. The reflexes are abolished, the skin and ex- 
tremities cold. A few convulsive efforts at breathing 
may occur, but they soon cease. 

Treatment is directed first, to opening up the respira- 
tory passage. The child is held up by the feet so the 
mucus, blood, and fluids may escape from the mouth. 
Compression of the chest wall will aid. The tracheal 
catheter is passed into the trachea and the mucus 
sucked out. Next, the skin reflexes are stimulated by 
slapping the back, or buttocks, and by blowing upon 
the face. 




Fig. 117. — Method of passing the tracheal catheter. (Hammerschlag.) 



The child at this time may be dipped in a tub of 
very warm water, (112° F.) and the chest and face 
sprinkled Avith cold water. Meanwhile, Laborde's 
method of traction on the tongue may be tried. The 
tongue is seized with tongue forceps (handkerchief, 
napkin, or piece of gauze will do) and rhythmically 
drawn out and released about ten times per minute. 

Further, the Byrd met hod of artificial respiration 
must be employed. 



280 



OBSTETRICS FOR NURSES 



The back of the child is held in the right hand, so 
that the thumb and forefinger grasp the neck loosely, 




Fig. 118. — Byrd's method of artificial respiration. Extension and 
inspiration. (iCdgar.) 




Fig. 119. — Byrd's method of artificial respiration. Beginning flexion and 
expiration. (Edgar.) 

the other hand holds the buttocks from behind and 
the body is slowly but firmly flexed between them until 
the thorax is compressed, then the grip is relaxed and 



CARE OF THE CHILD 



281 



the body widely extended to allow the air to rush into 
the lungs. This maneuver should be repeated about 
twelve times per minute. When the heart ceases to beat, 
the child is dead and respiration can not be established. 

The same treatment is employed for the apnoeic child 
born in Caesarean section and the oligopnceic child born 
under "Twilight Sleep." The method called "Schultze 
Swinging" is not to be recommended generally, on ac- 
count of the chilling which is so necessarily associated 




Fig. 120. — Byrd's method of artificial respiration. Flexion and com- 
pression. Note position of child which aids the escape of fluids from the 
mouth and nose. (Edgar.) 

with the exposure. The nurse should learn to practice 
all these methods of resuscitation. 

After the child breathes it must be watched carefully 
for at least forty-eight hours, lest the symptoms recur, 
and the child die. 

Asphyxia Neonatorum — 

(a) Livida — '< body congested — blue. 

(b) Pallida— body limp and pale. 
Remember possibility of patent foramen ovale. 



282 



OBSTETRICS FOR NURSES 



Etiology. — 

Too long compression of cord. 
Diminished irritability of medulla. 
Compression of brain during extraction. 
Shock during version. 
Aspiration of mucus. 

Treatment. — ■ 

Hold child by heels with head pulled back to straighten 

the trachea, and wipe out mouth and pharynx gently with 

cotton wound about the finger. 
Stimulate skin reflexes by slapping and blowing. 
Tracheal catheter, artificial respiration (Byrd) 8 to 10 

times per minute. 
Hot and cold bath alternately— rub the skin and knead 

the muscles. 

Laborde's method of traction on tongue 10 to 12 times 

per minute. 
Continue efforts so long as heart beats. 

Convulsions occur not infrequently during the first 
few weeks. They may develop as a result of injuries to 
the head during labor, or as a symptom of toxjemia. 
They may arise from constipation, from intestinal indi- 
gestion with curds, from fever or from haemophila. 
Meningitis and other infections are associated with this 
symptom, and occasionally atelectasis. They may also 
be the manifestation of a spasmophilic diathesis. The 
attack may begin with such premonitory phenomena as 
restlessness, muscular twitching, and staring of the 
eyes, but more frequently the onset is without warning. 
The facial muscles are contracted, the neck thrown 
back, the hands clenched and the extremities spasmod- 
ically cramped and tightened. There may be frothing 
of the mouth and consciousness is lost. Respiration is 
feeble, shallow and irregular. The face is discolored 
and strange rattling noises come from the larynx. The 
bowels and bladder may move involuntarily. The at- 
tack lasts from a few minutes to half an hour. 



CARE OF THE CHILD 



283 



Convulsions are not serious in all cases. 

The responsibility for the management of this com- 
plication usually falls upon the nurse. She calls the 
doctor, to be sure, but the attacks in many cases have 
ceased and the child may either be dead or out of danger 
of a recurrence before his arrival. 

The hot bath is a universal remedy and quite as effi- 
cient as anything. The temperature should be taken 
and the bowels washed out. 

If the fontanelles are tense when the doctor arrives, 
a spinal puncture may relieve the tension. A specimen 
of the blood is drawn through a needle and sent to the 
laboratory for examination. 

The cause must be found, if possible, and removed. 
A change of food may be all that is required. Cod-liver 
oil may be added to the diet in dram doses, three times 
a day, and milk curds, suspended in arrow-root water. 
For the acute condition, chloral hydrate is best. It is 
given by rectum, one or two grains in an ounce of water, 
and may be repeated in four hours. 

Atelectasis is the name given to a failure of the lungs 
wholly to expand during the efforts at respiration. The 
child may live for weeks with this affection, but usually 
it expires within a few days. 

In this condition, the child has a constant tendency 
to get blue, the color deepens, and death may occur 
in spite of every aid. The treatment may be perma- 
nently efficacious in some cases, but in most, the revival 
is only temporary. Again, the child may live, but in 
a weakly, declining state for days, until death comes. 

Aside from the physical signs of dullness elicited by 
percussion over the lungs, the most conspicuous symp- 
toms are the cyanosis and the intermittent but persistent 
whining cry. 



284 



OBSTETRICS FOR NURSES 




Fig. 121. — Method of giving gavage. (Grulee.) 



Treatment is by daily or hourly spanking, and by al- 
ternating hot and cold baths, by sprinkling with cold 
water or by massage to stimulate the skin reflexes. The 
treatment may have to be repeated every twenty or 
thirty minutes, and the earlier it is instituted, the more 
persistently carried out, the more chance of success. 

Exercise is just as important to the infant as to the 



CARE OP THE CHILD 



285 



adult. The kicking of the legs, moving' of the arms and 
lusty cry are all means of stimulating' the circulation, 
the muscular development, and the expansion of the 
lungs. The position should be changed occasionally in 
the crib from back to side and from side to back. Also 
the child's legs and back should be rubbed and mas- 
saged until the skin is red every time the bath is given. 

Flushing's. — The child is laid across the lap, or on a 
table. A rubber sheet is so arranged that the discharge 
will drain away. 

A soft rubber catheter, No. 18-20 French scale, is 
attached to a small funnel. The apparatus is boiled and 
filled with normal saline, or sterile water, at a tempera- 
ture of 85° F. to 95° F. Half a pint to a pint may be 
required. 

The catheter is oiled and passed into the rectum just 
beyond the sphincter. It must not go farther. The 
funnel is then raised and the fluid flows into the bowel. 
This flushing must not be confused with the administra- 
tion of an enema for constipation, for which, however, 
it is often an excellent substitute. 

Gavage is forced feeding by means of a tube. A soft 
rubber catheter or tube, about No. 7, French scale, is 
lubricated with albolene, vaseline or sweet oil. The up- 
per end is connected with a small tube or glass funnel 
holding two or three ounces. 

The child is laid upon its back in the arms of mother 
or nurse, the baby's arms are held and the head steadied. 

In case of diphtheria or scarlet fever, the tube may 
be passed through the nose and down the pharynx and 
into the oesophagus five or six inches, or even into the 
stomach. It is more convenient and easier when possible 
to pass it through the mouth directly into the stomach. 



286 



OBSTETRICS FOR NURSES 



The food is then poured into the funnel, which, by ele- 
vation, empties itself into the stomach. If regurgitated, 
more food must be given. When withdrawn, the tube 
should be pinched to prevent leakage into the trachea. 




Fig. 122. — Apparatus for gavage or lavage. (Tuley.) 

The great danger in these cases is the ease of over- 
feeding. 

Lavage or washing of the stomach may be performed 
in the same way with the above apparatus, when neces- 
sary. As soon as the stomach is filled, the tube is lowered 
and the fluid siphoned out. 



CHAPTER XX 



THE CARE OF THE CHILD (Cont'd) 

Tongue-tie is not met with so frequently as in the old 
days. If the child can suck and nurses energetically, 
this complication can be excluded. It may, however, 
occur. In such a case, the fraenum is unusually broad 
and seems to extend clear to the tip of the tongue, 
which apparently is bound down to the gum and to the 
floor of the mouth. 

The thin membrane may be snipped with the scissors 
close to the tongue and then torn back with the finger. 

Harelip and cleft palate interfere with nursing and 
require continual attention to keep mucus out of the 
throat. Brophy has a rubber flap placed over the nipple 
Of the bottle in such a way as to occlude the split tissue 
and thus enables the child to get nourishment. 

These babies must be fed systematically by gavage, if 
necessary, until the deformity can be repaired. 

Hernia at the navel is a common complication of in- 
fancy. It is not due to crying, to improper tying of the 
cord, nor to neglect by the nurse, as frequently charged. 
It is a congenital fault, wherein the cord opening does 
not close, and in time, crying and straining will drive the 
intestines out of the aperture like a pouch. The defect 
is revealed by the bulging outward of the navel when 
the child cries. Ordinarily the breach will close of its 
own accord. 

Treatment consists in folding up the skin of the 
abdomen so that the groove will be over the umbilicus 

287 




Fig. 124. — The device for feeding the child with cleft palate at the breast. 

(Brophy.) 



CARE OF THE CHILD 



280 



and include it. Then adhesive tape is put on to hold it. 
The surfaces of skin thus coming in contact should be 
dusted with rice powder or stearate of zinc. Another 
method of treatment is to place a wooden button form, 
round side down, on cotton, over the opening, and bind 
it, on with a zinc adhesive plaster. The dressing should 
be changed at least once a week. 

Inguinal hernia usually heals spontaneously also, but 
a truss may be required. 




Fig. 125. — Device for assisting the cleft palate child to nurse. (Brophy.) 

Haemorrhage of the newborn is either accidental or 
spontaneous. Accidental haemorrhage may arise from 
an imperfectly tied cord, or it may be an effusion, 
through compression or rupture, into any of the internal 
organs, such as the brain, lungs, or abdominal viscera. 
These latter conditions rarely give rise to symptoms, 
and are seldom recognized during life. There is no 
1 reatment. 

The intracranial haemorrhages are open to diagnosis 



290 



OBSTETRICS FOR NURKKS 



through the presence of pressure symptoms, but these, 
too, are impervious to treatment unless a vessel can be 
tied, like the middle meningeal artery. 

Spontaneous haemorrhages may develop during the 
first few days of life from sepsis, syphilis, Buhl's dis- 
ease, haemophilia, and true melaeria neonatorum. The 
fragile condition of the blood vessels, the great changes 
in the blood and circulation after birth, as well as con- 
stitutional dyscrasias, are etiological factors of impor- 
tance. All the causes are not as yet known. 




Fig. 126. — Method of strapping an umbilical hernia. 



The blood may come from the umbilicus, the mucous 
membranes of the eyes, nose, mouth, stomach and intes- 
tines. It may be effused into the tissues beneath the 
skin, or into any organ of the body. Marked nosebleed 
is generally syphilitic in origin. 

As a rule haemorrhages in the newborn are most com- 
mon in males, and strongly hereditary. 

The tendency to bleed lasts only a few weeks, and if 
recovery takes place, it is permanent. In some cases, 
however, where haemorrhage has developed in the brain, 



CARE OF THE CHILD 



291 



clots may form in important centers, and the child be 
permanently paralyzed in speech, sight, hearing, or in- 
telligence. 

Symptoms of haemorrhage begin during the first week 
and almost never after the twelfth day. The appearance 
of blood is the earliest and the most definite sign. The 
bleeding may come first from the umbilicus, or from the 
stomach, or from the intestines (melsena neonatorum). 
The amount lost is small, but the oozing is continuous. 
The temperature may be high or subnormal, and may 
or may not be due to the haemorrhage. The skin is pale, 
the pulse feeble, prostration marked, and weight is lost 
rapidly. Convulsions are not infrequent. 

Tht diagnosis of the condition is simple. It is only 
necessary to be certain that the blood is really effused, 
and not a temporary or accidental event such as the 
regurgitation of swallowed blood. Black tarry stools 
will show blood if placed in water. 

The prognosis is not good. About two-thirds of these 
babies die. 

The treatment is to stop the haemorrhage by ligature, 
suture, or compression if possible and to alter the char- 
acter of the blood by adding to its fibrin content. This is 
brought about, if at all, by the administration of 
coagulose, coagulen ciba, or by transfusion from an 
adult — preferably the father. 

Paralysis of the face (Bell's paralysis) may follow the 
use of forceps. The prognosis is favorable. Paralysis 
of the nerve in the neck (musculospiral) is sometimes 
known as Erb's paralysis. It happens in consequence 
of difficult breech deliveries or of vertex labors when 
much force is required to extract the shoulders. 

The deltoid, biceps, and other muscles are affected so 
that the arm can not be raised. The failure to raise one 



292 



OBSTETRICS FOR NURSES 



arm will be the symptom that will attract the attention 
of the nurse. Some cases recover in a month or- so, 
either spontaneously or by the aid of electricity. If not, 
the injured nerve must be cut down upon and its con- 
tinuity restored. 

Ophthalmia neonatorum is an infection of the eyes of 
the newborn by the gonococcus. The infection occurs 
as the child passes through the vagina or vulva, or when 
an unclean finger is put into the eye. 

The reaction is violent. The discharge at first is thin, 
then thick, pus. If untreated, the eyesight may be lost 
by ulceration. In the asylums twenty-five per cent of 
the inmates are blind from this infection; and as late 
as 1896, seven per cent of the blindness in the state of 
New York could be traced to this avoidable disease. 

The preventive treatment consists in the frequent 
douching of the vagina before labor with potassium 
permanganate solution 1 : 5000, or chinosol 1 : 1000. 
After labor, a drop or so, of 1 per cent solution of nitrate 
of silver is dropped into each eye and not neutralized. 

After the infection has occurred, iced compresses are 
applied to the eye, night and day, and a solution of 
argyrol 15 to 20 per cent instilled into the outer corner, 
twice a day. In female infants with ophthalmia, the va- 
gina must be watched for discharge which does not fail 
to appear in most cases. Argyrol (20 per cent) should 
be injected with a medicine dropper and left to drain out 
spontaneously. All dressings used about the child should 
be destroyed, and the nurse should use the most scrupu- 
lous cleanliness and care of her own person. 

Separation of the cord may be delayed in puny babies 
and in cases where the cord is large and thick. 

Some of these cases are doubtless due to a patency or 
fistulous condition of the urachus. Usually the separa- 



CARE OF THE CHILD 



293 



tion may be hastened by touching the constrictured part 
with silver nitrate. Or, if the cord does not separate be- 
fore the second week, it may be desirable to cut off the 
hanging fragment and touch the base Avith silver nitrate 
or dust with alum powder. 

Granulations may protrude like a mulberry from the 
stump of the navel ("proud flesh"). These are touched 
with nitrate of silver stick. 

Menstruation may appear occasionally from the vulva 
of the newborn. It is really a haemorrhage, a menstrual 
flow, which is associated with uterine activity, but 
rarely significant. There is no treatment. It disappears 
spontaneously. 

The breasts of the newborn may fill with milk and 
become indurated and tender. Nothing should be done 
to them. Let them alone and the swelling will subside 
in a few days and the milk ("witches' milk") dis- 
appear. 

Icterus may develop from the third to the sixth day. 
The child becomes yellow and stays yellow for a week, 
Avhen the color gradually leaves. It is thought to be due 
to the liberation of some embryonic residue in the foetus, 
but nothing is known certainly. For the simple form 
no treatment is required. Recovery is prompt and un- 
eventful. However, jaundice is associated with other 
conditions that prove fatal, hence every icterus should 
be watched carefully until it disappears. 

Child's Nails. — The nails are frequently rough and 
ragged at ends and sides. They should be smoothly 
trimmed lest they become infected at the junction with 
the skin and give rise to paronychia. If infection does 
occur, the skin and flesh may be pushed back with a 
sterile applicator, and the point touched with peroxide 



294 



OBSTETRICS FOR NURSES 



of hydrogen. A syphilitic history may be traced in some 
of the babies. 

Thrush is a form of contagious soreness, characterized 
by white flakes or patches on the mucous membrane of 
mouth or anus which look like milk, but can not be 
wiped off. 

It is due to a vegetable fungus and occurs most fre- 
quently among anaemic or poorly nourished babies or 
those suffering from harelip. It is associated with symp- 
toms of indigestion. 

It may always be prevented by keeping the mouth 
and nipples clean, as directed on another page, and by 
keeping the bottles and rubber nipples in a solution of 
boric acid Avhen not in use. When the disease appears, 
the mouth must be swabbed three or four times a day 
with an applicator soaked in saturated solution of boric 
acid. This is curative. 

Aphthae or stomatitis is the name given to whitish 
vesicles, followed by superficial ulcers that occur upon 
the inside of mouth and lips of the infant. It is rare in 
the newborn child. Boric acid solution is cleansing, and 
stick alum, frequently applied, will effect a cure. 

Wheals, urticaria or "stomach spots" appear as gen- 
erally distributed small spots about the size of a split 
pea, with a white center and a red periphery. They ap- 
pear about the third day and last twenty-four hours. 

They may be mistaken for insect bites and they may, 
or may not, be accompanied by temperature, which is 
probably only a coincidence. 

The wheals disappear spontaneously without treat- 
ment. 

Bednar's disease is characterized by the appearance 
of two ulcers on the hard palate, one on either side and 
just above the spot where the last tooth will erupt. It 



CARE OF THE CHILD 



295 



is most liable to occur in sickly infants and supposedly 
arises from the abrading- of the mucous membrane by a 
rubber nipple or through the rough cleansing of the 
month. It is very resistant to treatment. The child 
must be put in good condition by attention to the 
nourishment and the spots touched with tincture of io- 
dine on an applicator. 

The exudative diathesis is indicated superficially by a 
definitely bounded red patch on either cheek, which is 
not relieved, or oidy temporarily, by the common oint- 
ments and powders. The mother says the "face is chap- 
ped," or that the baby has a "milk eczema." Other- 
wise the skin is pale. 

These children are frequently fat, but the tissue is 
flabby. The urine is sometimes ammoniacal. There is 
no marked disturbance of temperature. Fretfulness 
and constipation are the principal symptoms. 

The condition is due to too much fat in the food. A 
skimmed-milk diet is best for a time. The fat can be 
added gradually until the limit of tolerance is found. 

If chalky masses appear in the stools, the fat must 
be reduced again. Occasionally the child must be taken 
off the milk entirely, and a soup or gruel diet sub- 
stituted. 

For local application, the following formula is some- 
times beneficial : (Grulee.) 



R Naphthalene 



5i 

3iv 

.3iv 



Starch 

Zinc stearate 
M. 



Sig. Apply frequently. 



The "cradle cap" is a frequent sign of the exudative 
diathesis in its milder stages. 

The term is applied to a yellowish-gray patch over the 



290 



OBSTETRICS FOR NURSES 



large fontanelle. The mother calls it "dirt," which she 
finds hard to remove and it always recurs. The mass 
is composed of dry scales, which gradually change into 
an eczema. Vaseline or sweet oil left on over night 
makes the removal of the scales quite easy the next day. 
If a raw surface is left, zinc ointment should he applied. 
The diet must be changed as previously described. 

Erythema, especially of the diaper region, is some- 
times a manifestation of congenital syphilis. It is usu- 
ally limited to the inner side of the thighs, the perineum, 
scrotum or vulva, and buttocks. It must be associated 
with other and more characteristic signs, however, such 
as snuffles, cachexia, etc., before it becomes diagnostic 
of syphilis. Most erythemas of this area are due to ir- 
ritation from moist or soiled diapers, but other factors 
may be important. Bluing in the diaper, gastrointes- 
tinal troubles, and circulatory disturbances are con- 
tributing causes. The local treatment is the same as for 
intertrigo. If the child is syphilitic, systemic meas- 
ures must be instituted. 

Intertrigo, or chafing, is a form of eczema due to 
moisture, bluing in the diapers or uncleanliness. The 
child should be cleaned with oil instead of water, and 
well powdered with stearate of zinc or zinc ointment may 
be used. Talcum powder which contains boric acid is 
contraindicated. 

Pemphigus neonatorum is an eruption of blisters or 
blebs which seem to follow infection from the maternal 
passages or to be communicated by other babies who 
have the disease. 

From three to fourteen days after birth, the blebs 
develop on the abdomen, neck or thighs, and show a 
tendency to spread to other parts of the body. The 
vesicles vary in size from one-fourth of an inch to two 



CARE OF THE CHILD 



297 



inches in diameter, and contain a serous, purulent, or 
bloody fluid. Other signs of general sepsis may appeal'. 

In diagnosis care must be used to exclude syphilis, 
which also exhibits blebs, but usually on the soles of the 
feet or the palms of the hands. Besides, a nonsyphilitic 
child is generally better nourished. The prognosis is 
unfavorable if the child is weakly, if the blebs spread 
rapidly over a large area, or if the infection attacks the 
umbilicus. 

Treat me nt. — A rigid quarantine must be enforced. 
In the hospital no new cases can be admitted. The 
alimentation must be increased, the blisters evacuated, 
and the surfaces cleaned and covered with a 25 per cent 
ointment of ichthyol, or an ointment of ammoniated 
mercury 2 per cent. 

Strophulus, red gum, or miliaria rubra are names ap- 
plied to an inflammation of the sweat glands when their 
secretion is retained. It is a "sweat rash" character- 
ized by an eruption of scattered red papules or small 
vesicles which commonly appear on the cheeks or neck 
of young infants, or where skin surfaces come in contact. 
It is due to excessive clothing or heat. It is really a 
prickly heat. The treatment consists in the removal of 
the cause, and a generous use of stearate of zinc powder 
or rice powder. 



CHAPTER XXI 



THE CARE OF THE CHILD (Cont'd) 

Constipation in the newborn may come from many 
causes. The amount of food may be so inadequate that 
no residue is left, and the bowels move only once in 
forty-eight hours. Over-stimulation of the bowel by 
castor oil or colonic flushings in the early weeks of life 
to correct colic may diminish its sensitiveness and pro- 
duce atonic constipation. In the artificially fed infant 
too much fat in the food is a very common cause of the 
trouble. 

Treatment. — Correct the amount of fat in the milk. 
If the child is breast-fed, the mother's diet should be 
non-nitrogenous and vegetables should preponderate, 
Drugs should not be given until all else has been tried. 
Gluten suppositories will furnish a mild irritation to 
the rectum. Orange juice and prune juice may bo 
given, or Mellin's food or oatmeal water added to the 
milk. Milk of magnesia V2 to 1 teaspoonful, or Hus- 
band's magnesia, in same dosage, may be given daily. 
Senna is also efficacious. 

Diarrhoea is generally significant of an error in diet 
which is usually a plain indigestion, though there may 
be too much sugar in the food. 

The stools are more frequent and always softer than 
usual, possibly fluid. 

Diarrhoea means increased intestinal action due to ir- 
ritation from something. It may be due to indigestion, 
to the presence of hard curds, to acidosis, or it may ac- 
company almost any disease of infancy as a symptom 

298 



CARE OF THE CHILD 



299 



merely. The odor is due to gases formed in the canal 
by bacterial action. There is but little odor in fermen- 
tation, but much in putrefaction. Mucus appears either 
as balls or strings. The balls come from the small in- 
testine, strings from colon. Blood indicates ulceration 
at some point in the bowel, or an erosion just above the 
sphincter. 

Fatty curds may be either white, granular, sand-like 




Fig. 127. — Proper position for introduction of a suppository. (Grulee.) 



masses, or small, soft, and yellow. The protein curd is 
large and smooth, or white and bean-like. Both occur 
only when the artificially fed infant is given raw milk 
(Brenneman). If the milk is boiled for two minutes 
these masses will not form. 

The cause must be determined. The frequent stools, 
however, are exhausting, and may have to be checked 
with opiates or mechanical astringents. 



300 



OBSTETRICS FOR NURSES 



When due to indigestion, all food by mouth may be 
stopped for two or three days and only barley water 
administered. 

In a breast-fed child, diarrhoea is sometimes cheeked 
by diluting the milk with a little barley water, given 
just before nursing. With these infants, not much 
change in the sugar content can be made by alterations 
of the maternal diet, but where artificial food is used, 
the amount of sugar is easily reduced to a satisfactory 
degree. 

Colic is a cramp-like pain of the bowels. Previous 
to the attack the child is restless, expels some gas, and 
has the "colic smile," which leads the mother to believe 
the child is quite well. When the attack comes on, the 
thighs are flexed on the abdomen, and the legs on the 
thighs. The child has a sharp cry, that is nearly con- 
tinuous, but in some way related to the nursing period, 
for the attack comes on a few minutes, and sometimes 
an hour, after taking the breast, The belly is rigid, the 
arms wave aimlessly. Diarrhoea may be present, and 
the movements are accompanied by much flatus. Dis- 
tention is nearly always present. When the belly is 
tapped it gives a drum-like note and the child belches 
gas, sometimes accompanied by milk, which seems to 
relieve. 

Treatment. — Colonic flushings to relieve the bowel 
of irritating curds. The child may be laid face down 
with a bag of hot water under the belly. Mixture of 
asafcetida gtts. xx to xl, or whiskey and hot water 
should be given for the attack, followed later by a full 
dose of castor oil. The diet should be rigorously in- 
vestigated. 

Vomiting may or may not be serious. The child may 
nurse too rapidly or too much, and the over-distended 



CARE OF THE CHILD 



301 



stomach simply empties itself. Many infants "spit up" 
their excess of milk, and thus relieve themselves. This 
is a simple regurgitation, usually of unchanged milk, 
though it may be acid from admixture with the gastric 
juice. 

Vomiting, in a breast-fed child, may come during an 
attack of colic when the eructations of gas appear. It 
may be a symptom of gastrointestinal intoxication, of 
too much fat in the food, too short intervals between 
feedings, or too much sugar in the food. 

Projectional vomiting awakens suspicion of a pyloric 
stenosis or meningitis, and must be reported to the 
physician at once. 

Vomiting which occurs within twenty minutes after 
feedings is not serious ordinarily, even though gas and 
large curds are expelled, but all vomiting later than 
this, is significant of a pathology. 

Treatment. — Regulation of the hours of feeding is 
most important, and next, the character of the food. 
If the child vomits an hour or so after nursing, it may 
be that the milk is too rich (fat). Try a longer inter- 
val, or give an ounce or so of cereal water before put- 
ling the child to the breast. 

Prematurity exposes the child to three distinct dan- 
gers, which arise, respectively, from atmosphere, food, 
and infection. Very few children born before the 
seventh month survive. A child born at the eighth 
month, or with a weight of three pounds, or more, can 
be saved almost always. The premature child up to 
the time of birth, has been protected very carefully 
against temperature variations by the liquor amnii, and 
when suddenly precipitated into a new environment, 
which its vitality barely tolerates, the consequences are 
serious. 



302 



OBSTETRICS FOR NURSES 



These infants have a poor heat production, and the 
natural warmth of the body must be preserved. This 
is best done by incubators, which supply air and mois- 
ture in stable and appropriate amounts. Chilling of the 
child for even a few moments may be fatal. A room 
may be fitted up to produce the necessary conditions 
of light, air, heat and moisture. The child, wrapped 
in sheets of cotton, except the face, is then covered 
with a blanket, and surrounded by a temperature vary- 
ing from 88° to 95° P., which is gradually lowered to 
80° F. as the child gains strength. An occasional whiff 
of oxygen, as prescribed for an atelectatic child, is 
sometimes advantageous. 

Bathing. — Premature infants must not be bathed, but 
the skin should be cleansed with cotton and warm 
sweet oil or albolene. All unnecessary handling is to be 
avoided. 

Food. — Breast milk is the secret of success with these 
cases. Since most of the infants are too weak to take 
the nipple, the breasts must be pumped, and the child 
fed with spoon or pipette. 

The interval between the feedings depends a little on 
the amount taken, but it should not be less than one 
and one-half hours, nor more than two hours. As the 
child gains, the interval may be lengthened to three 
hours. Lack of sufficient nourishment is shown by 
cyanosis and loss of weight, and overfeeding, by vomit- 
ing and diarrhoea. 

The child must be fed by hand until strong enough 
to nurse the breast. In certain cases of prematurity, as 
well as in diseases like pneumonia, scarlet fever, and 
diphtheria, the child must be fed by gavage. Nutritive 
inunctions of benzoated lard or cod-liver oil are also 
valuable, not only for the passive exercise supplied, but 



CARE OF THE CHILD 



303 



for the absorption of a certain amount of the unguent. 

Marasmus means wasting, but the term is applied to 
infants that steadily lose weight, The bodies of infants 
are so largely composed of fluid, that loss of weight 
occurs quite easily and rapidly. Loss of weight may 
be sudden or gradual. It comes on rapidly after acute 
diarrhoea, either with or without vomiting, or it may 
follow persistent vomiting without diarrhoea. 

Malnutrition from defective feeding is the most com- 
mon cause of wasting in infants. This may be from lack 
of sufficient food or lack of proper ingredients, as well 
as irregularity of intervals, and disease. Rickets, con- 
genital stenosis of the pylorus, congenital syphilis, and 
tuberculosis are all possible factors in the etiology. 

In any case, no treatment can be instituted until these 
conditions have been confirmed or excluded. 

Pyloric stenosis (the account follows Grulee) may be 
a thickening of the muscular coat of the outlet of the 
stomach (pylorus) or a spasmodic contraction. The 
condition is most frequent in males and in the first 
born. 

Symptoms usually begin before the second week. 
There is constipation with small ribbon-like stools, and 
the urine is scanty. The most marked sign, however, 
when it is present, is the excessive, uncontrollable vom- 
iting, which ordinarily occurs fifteen to thirty minutes 
after eating, but may be delayed for several hours. The 
vomiting may be of the common type, but more fre- 
quently it is projectile in character, like that seen in 
meningitis. The contents of the stomach are violently 
expelled, sometimes several feet. Physical examination 
may reveal the stomach bulging under the arch of the 
l ibs and peristaltic waves moving back and forth across 



304 



OBSTETRICS FOB NURSES 



its surface. The pylorus itself may sometimes be felt 
as a lump or tumor. 

Prognosis. — About fifty per cent die. 

Treatment. — Dietetic and surgical. Grulee recom- 
mends small amounts of food, poor in fat, be given at 
short intervals. If this fails, operation is required. 

Pneumonia in the newborn most frequently results 
from the aspiration of mucus out of the maternal pas- 
sages as the child is born. This may happen when the 
cord is compressed, or at any time when a partial as- 
phyxiation impels the child to try to breathe. 

It may also come on when a feeble child has been 
chilled by a prolonged first bath. 

The disease develops about twenty-four hours after 
birth in a child apparently well. The temperature rises, 
respiration becomes rapid, and cough develops. The 
child is fretful, restless, refuses the nipple, and gasps for 
breath. It may become cyanotic. The prognosis in new- 
born infants is very serious. 

Treatment is stimulation. A mustard bath will bene- 
fit where the respiration is rapid and the child blue. 
Tincture of digitalis may be administered in drop doses 
every three or four hours. Carbonate of ammonia, 
% gr., in mucilage of acacia, half a dram, may be given 
for cough. 

Child must be fed on mother's milk pumped from 
breast. 

Snuffles may be due to improper clothing, to drafts 
of air, or to syphilis. If due to cold, camphorated oil 
may be rubbed on the nose and the passages kept clean 
with an applicator soaked in albolene. If this fails, a 
small pellicle of anaesthone may be placed in each nostril, 
and the child laid upon its back until the ointment melts 
and runs back into the pharynx. 



CARE OF THE CHILD 



305 



Furuncles (boils) may be numerous. They come from 
irritation of the skin by atmosphere, soap, water, and 
clothing, whereby infection enters. This is especially 
liable to occur in the hair. 

Keep the boils washed with boric acid solution and 
open them as soon as the focus, or head, appears. 

Phimosis is such a close adjustment of the prepuce 
to the glans penis that it can not be retracted. In 
some cases there may be obstruction to the outflow of 
urine, but generally a tiny portion of the glans can be 
seen. The prepuce may or may not be redundant. 
This condition makes cleanliness impossible and balan- 
itis may result. 

On account of the straining required to urinate, pro- 
lapsus ani, hernia, and hydrocele of the cord sometimes 
develop. Symptoms may arise from preputial adhe- 
sions, as well as phimosis. Frequent or difficult mictu- 
rition, nocturnal incontinence, priapism, pruritus, and 
masturbation may develop out of the irritation, as well 
as nervous manifestations, such as insomnia and night 
terrors. 

The condition should be recognized and corrected in 
infancy. If the adhesions are dense, an incision can be 
made down the dorsum of the prepuce, the tissue forci- 
bly separated from the glans, and the flaps cut off. 
Stitches may be required. In other cases circumcision 
may be necessary. 

Paraphimosis. — When a prepuce with a small orifice 
is forcibly retracted over the glans, it occasionally hap- 
pens that it cannot be pulled forward again. If al- 
lowed to remain this way, the parts will swell, and the 
penis become strangulated as if with a ligature. 

The danger arises from the stoppage of the circulation, 
which may be followed by ulceration and gangrene. 



306 



OBSTETRICS FOR NURSES 



Reduction must be brought about by manipulation, 
if possible, but where this fails, the constricting' band 
must be cut through and sedative applications used. 

Balanitis is inflammation of the prepuce from the de- 
composition of smegma, which collects under a tight 
foreskin. The condition is quickly relieved by clean- 
liness and a few applications of vaseline or zinc oxide 
ointment. Circumcision should not be done until the 
inflammation has subsided. 

Circumcision, either as a physical necessity or as a 
religious rite, is frequently performed. 

The nurse prepares a table with sterile linen, a basin 
with antiseptic solution and sponges, sterile towel, and 
sterile vaseline, with a roll of gauze bandage an inch 
wide. 

The object of the operation is to remove the prepuce 
and leave the glans exposed. 

The instruments needed are a pair of sharp scissors, 
a pair of dissecting forceps, two pairs of artery for- 
ceps, small, full curved needles, and fine catgut. 

The nurse gives the child some gauze to suck, which 
has been soaked in brandy and sugar-water, brandy 
one dram to an ounce of water. Then taking her place 
at the child's head, she flexes the thighs back upon the 
abdomen, and widely separates them. The field of op- 
eration is thoroughly washed with soap and warm wa- 
ter, the prepuce is then retracted and the smegma 
wiped away. Then the body and limbs should be cov- 
ered with clean linen, except the penis, or a sterile 
towel may be used with a hole in it through which the 
penis is drawn. The redundant tissue is removed and 
fine catgut sutures put in. 

The operation being completed, the wound is covered 



CARE OF THE CHILD 307 

with sterile vaseline and wrapped with a sterile gauze 
bandage, leaving the end of the glans exposed. 

The gauze and vaseline are changed whenever sat- 
urated with urine. Healing ought to be complete by 




Fig. 128. — Hydrocephalus. (Bumm.) 



the seventh day. The nurse should examine the dress- 
ing at frequent intervals during the first twenty-four 
hours, since serious hemorrhages may occur from ves- 
sels that have not been included in the sutures. 



308 



OBSTETRICS FOR NURSES 



Priapism is a condition of functional fullness and 
firmness of the penis that is more than ordinarily con- 
stant. Its importance lies in the fact that it may be a 
symptom of spinal irritation, balanitis, worms, or 
phimosis. 

Spina bifida is the most common congenital deform- 
ity. It is characterized by a fluid tumor, which pro- 
trudes from an opening in the vertebral column. It 
may appear anywhere along the spine, but is found 
most frequently in the lumbar or cervical region. The 
deformity is supposedly due to an arrest of develop- 
ment. It is nearly always fatal inside of two weeks, 




Fig. 129. — Anencephalus. (Williams.) 



though cases have been known to reach mature years. 

There is no treatment except protection from injury. 

Hydrocephalus is sometimes, but not necessarily, as- 
sociated with spina bifida. 

The ventricles of the head are filled with cerebro- 
spinal fluid, and the fontanelles are widely separated. 
The cause of the anomaly is unknown. 



CARE OF THE CHILD 



309 



This condition may render labor difficult or impos- 
sible until the diagnosis is made and the skull perfor- 
ated. Rupture of the uterus may result from the futile 
efforts to expel the child. If born alive, the child 
nearly always dies, or if it grows up, the intelligence 
is imperfect in most cases. 

Anencephalus is a monster, having a body, but only 
a part of a head. The eyes protrude, the tongue may 
hang from the mouth, and the brain is under-developed. 

Sudden death of infants that are apparently healthy 
comes with a shock to the physician as well as the par- 
ents, and in some instances, no plausible reason can 
be assigned for it. Apoplexy, pneumonia and stoppage 
of the trachea by milk curds may explain some cases. 
Suffocation by lying on the face in wet bedding, or 
overlying by the mother will account for others. In- 
ternal haemorrhage into lungs, pleura, stomach, or brain 
is also known to be causative. 



CHAPTER XXII 
INFANT FEEDING 

A well fed infant is a happy little animal, who sleeps 
approximately twenty-two hours a day, and gains from 
four to six ounces a week. If properly fed at the 
breast, this condition is easily obtained ; but if artifi- 
cial food is necessary, the resources and skill of the at- 
tendants may be tried to the utmost before the wel- 
come result is brought about. 

The feeding of infants may be considered under three 
heads, (1) the breast; (2) breast and bottle combined 
(mixed feeding); and (3) artificial, which is really mod- 
ified cow's milk. 

Breast feeding has been taken up elsewhere, but the 
same care should be taken in feeding from the bottle 
as in feeding from the breast, so far as concerns the 
intervals between the feedings and the duration of the 
same. Since it takes from one to two hours longer for 
cow's milk to digest than it does for mother's milk the 
longer interval of three or four hours between feedings 
is better for the artificially fed child. With such an 
interval there will be less vomiting, less colic, less ten- 
dency to overfeed, and a better natured baby. 

One feeding should be omitted at night, and if pos- 
sible, two. 

Length of time for taking the bottle depends some- 
what on the child, but it should not exceed fifteen min- 
utes, as a rule. 

Supplemental Feeding'. — A mother who has too little 

310 



INFANT FEEDING 



311 



milk may have it supplemented by a modified mixture 
in one of two ways. 

First, the quantity furnished by the breast must be 
determined by weighing the infant before and after 
feeding, and then the total amount for twenty-four 
hours can be deduced. "With this information, it is not 
difficult for the doctor to know how much cow's milk 
to prescribe. The supplemental feeding may be given 
by alternating the bottle and the breast, or by giving 
the breast and following it immediately with the bot- 
tle. In the meantime, the mother must be put on tonics 
with an abundance of fluids, and a generous diet that 
will raise the blood pressure, in the hope that the milk 
will increase sufficiently to enable her to feed the child 
entirely from the breast. 

When it becomes necessary to substitute some other 
food for the breast milk, it means that the milk of some 
other mammal must be modified for the purpose. The 
most convenient and abundant source of supply is the 
cow. 

While in many respects cow's milk is similar to moth- 
er's milk, it is in reality quite a different product. 
Mother's milk is taken, undiluted, directly from the 
breast, Avhile cow's milk is given from a bottle, hours 
after milking, and not only must it be diluted, but cer- 
tain ingredients must be added to aid its digestibility. 

When taken into the stomach in its natural state, 
mother's milk is a liquid, while under the same con- 
ditions, cow's milk forms a semisolid gelatinous mass. 

It is essential that the milk should be as fresh, clean, 
and free from bacteria as possible, and this can be ap- 
proximated only in certified milk. This milk is re- 
quired by law to have its constituents definitely stand- 
ardized. Thus, there must be 4 per cent of fat, 4 per cent 
of protein, and 4 per cent of sugar, and it must be so free 



312 



OBSTETRICS FOR NURSES 



from bacteria that not more than 10,000 per cubic cen- 
timeter can be found. The cattle also are tuberculin 
tested. The following comparison is from Holt: 



Mother's Milk 

Sp. Gr. av. 1.031 

Fat 4. % 

Protein 1.50% 

Sugars, 7. % 

Salts 2 % 

Water 87.3 % 

Eeaction Alkaline 



Coiv's MUk 

av. 1.081. 

Fat 4. % 

Protein 3.50% 

Sugars 4.50% 

Salts 75% 

Water 87.3 % 

Eeaction Acid 



Bacteria Very few Bacteria Many 

Both range from 1.026 to 1.06. 




Epithelium 

Fig. 130. — Elements of human milk. (Fdcn.) 



The fats are substantially the. same, but the fat of 
cow's milk is less easily digested than the fat of moth- 
er's milk. 

The protein of mother's milk is virtually half lact- 
albumin and half casein, which is only slightly coagu- 
lated into soft flocculent curds by the action of rennin 
and acids, while the casein of cow's milk is nearly three 



INFANT FEEDING 



313 



times greater in amount than the lactalbumin and is 
coagulated into coarse, tough curds. 

The sugars in both cases are lactose in solution, but 
mother's milk contains a much higher percentage. 

Cow's milk contains three times the quantity of salts 
found in human milk, but the water is the same in both. 

So, while the two milks seem in comparison to be 
much alike, in reality they are quite different ; hence it 
is necessary to modify cow's milk in such a way as to 
make it not like mother's milk chemically, but to make 
it act like mother's milk. 

It is extremely difficult to bring up an infant on arti- 
ficial food, and inasmuch as half the infants that die 
during the first year, perish from intestinal disorders, 
it is imperative that every resource should be exhausted 
before the breast feedings are abandoned. It is fal- 
lacious to believe that anyone can feed a baby, or that 
feeding consists merely in trying one food after an- 
other until one is found to agree. Only a competent 
physician should prescribe the food, and he should 
study his problem and make his modifications just as 
he would alter his medicines for a particular disease. 

However, it Is necessary for the nurse to know how 
to carry out the doctor's orders intelligently and how 
to report to him the conditions present. 

In prescribing for the child, the doctor usually has 
some definite outline in his mind, such as 

Age and weight. Example: 3 months old; weight 10 

pounds; 7 feedings; 1 every 3 hours. 

Interval, three hours. 

Amount in each bottle, four ounces. 

Formula: 

Milk, 12 oz. 

Diluent, 16 oz. (Cereal water or plain water.) 

Sugar, % oz. 

Flour ball, if any, y 2 oz. 

Boil if ordered. 



314 



OBSTETRICS FOR NURSES 



The infant should not take more than two ounces of 
milk to a pound of weight in each twenty-four hours. 

Proprietaries. — Baby foods are not to be recom- 
mended nor condemned. They are placed on the mar- 
ket as substitutes for mother's milk with definite in- 
structions as to preparation. They are also very ex- 
pensive. They are not to be condemned, because many 
of them are invaluable when used in connection with 
cow's milk. Sometimes a child will not tolerate any- 
thing but malted or condensed milk, or Nestle 's food, 
for example. The malt sugars, such as Horlick's and 
Mellin's, are easily assimilated, fattening, and laxative. 

All foods in the modification of milk should be of the 
best. The standard sugars are Merck's milk sugar, 
Mead's Dextri Maltose, Nahrzucker, cane sugar, and 
Mellin's and Horlick's foods. Robinson's barley flour 
or Johnson's are the best known. Imperial granum is 
a partially dextrinized flour and corresponds to the 
home-made "flour ball." 

FOOD PREPARATION 

Buttermilk Made from a Culture. — Bring two quarts 
of milk to a boil, cool to the temperature required for 
inoculation (80° to 100° F., depending on the culture 
employed). Introduce the culture, and allow it to stand 
at the temperature of the room until a solid clabber 
forms. Place on ice, whip with an egg beater or break 
up with a churn before using. If a fat-free butter- 
milk is desired, use skimmed instead of whole milk. 

There are many kinds of buttermilk cultures on the 
market, but Hansen's is considered one of the best, be- 
cause it is not too acid, besides Avhich, it has a good 
flavor, and the culture can be utilized over and over 
for a week or ten days. 



INFANT FEEDING 



315 



Iii preparing a subsequent portion, it is only neces- 
sary to use two or three ounces of the first buttermilk, 
which may be reserved for the purpose. This amount 
is introduced into the freshly boiled milk, instead of 
the original powder, and the preparation is continued 
exactly as described for the mother culture. 

In every case the mixture must be placed on ice as 
soon as the clabber forms, as it becomes too sour other- 
wise. 

Eiweiss Milk. — Heat one quart of whole milk to 
145° F. and coagulate with pepsin, rennin, or chy- 
mogen, which is 10 per cent rennin. Let it stand until 
clabbered, which takes about ten minutes. Pour into 
a gauze bag and let it stand until all the whey is 
drained off. To the dry curd, add 1/2 ounce of flour 
ball, and one pint of skimmed buttermilk, the whole 
to be rubbed through a very fine wire mesh sieve (as 
fine as a tea-strainer, at least), three separate times; 
or, it may be ground twice through a special mill to 
break up the curd as minutely as possible. Add a pint 
of water and measure. There should be a quart and 
three or four ounces over. Place upon a slow fire and 
bring to a boil while stirring constantly. Boil two min- 
utes, then cool, strain, measure, and add water to make 
up for evaporation. Shake well before measuring, as 
the curd is heavy and settles to the bottom. 

Peptonized Milk.— (See p. 338.) 

Whey. — To a pint of fresh, warm cow's milk, add 
rennin as pepsin, or chymogen, and stir until mixed. 
Let it stand until coagulation is complete. Then the 
curd should be broken up with a fork, and the whey 
drained off through coarse muslin. This removes the 
eoagulable proteins from the milk. A ten per cent 
cream can be had at home by allowing a quart of milk 



316 



OBSTETRICS FOR NURSES 



to stand for six hours and then using the upper one- 
fourth. 

Whey-Cream Mixture. — Make whey as described and 
mix with cream, in the proportion of whey 11/2 ounces 
to cream, 1 dram for each feeding. 

Barley Water. No. 1. — Use one ounce of barley 
pearls to a quart of water. Wash thoroughly, put on 
a slow fire and boil for six hours. Add water to make 
up for evaporation, and add a pinch of salt. Strain 
and cool rapidly. 

Barley Water. No. 2. — Use one heaping teaspoonful 
of Robinson's patent barley flour to each pint of cold 
water. Boil twenty minutes and add water to make 
up for evaporation. Add a little salt, strain and cool 
rapidly. 

Other cereal waters, like rice and oatmeal, are made 
like barley water No. 1, and in the same proportion. 

Flour Ball. — Take four cups of ordinary wheat flour 
and wrap it in a piece of muslin, and tie it tightly. 
Drop the mass into boiling water and boil six hours. 
Then take it out, cool it and remove the outer peeling 
with a sharp knife. Break into small pieces, the size 
of an English walnut, and dry thoroughly in a slow 
oven. Pulverize in a mill or meat-grinder, sift and 
keep in a dry place. 

Milk may be sterilized, pasteurized, or boiled. 

Sterilization kills botli germs and spores, but it is 
not nearly so necessary as it is to have the right pro- 
portion of sugar and fats. Place in an autoclave and 
keep at a temperature of 160° F. for an hour. 

Pasteurization is desirable when a good, clean milk 
is not attainable. It kills the germs, but not the spores. 
The process must be carefully attended to, or the milk 
will sour more easily. Heat a quart of milk to 160° F. 
for twenty minutes. Cool rapidly to 40° F. 



INFANT FEEDING 



317 



Boiliiif/ milk for two minutes kills all bacteria, and 
renders the casein more easy of digestion and prevents 
the formation of curds. 



Whole milk contains 4 per cent fat, and must be 
thoroughly shaken before it is measured, for otherwise 
one child will get all the fat and another all the 
skimmed milk. 

Fat-free, or skimmed milk, contains about 0.1 per 
cent fat. The cream has been removed by a siphon or 
centrifuge. If unable to get a fat-free milk from a 
dairy, the cream can be removed from a quart of whole 
milk quite easily with a siphon. 

Sugars and flours should be weighed when used, for 
they vary greatly in volume. 

In using flour ball or imperial granum, the flour must 
be mixed with water or cereal water, to make a smooth 
paste and brought to a boil. If the milk is to be boiled 
also, add the milk to the paste and boil all together. 
Cool and strain. 

All baby feedings should be strained, as tiny lumps 
of food will clog the rubber nipple and the nurse may 
think the baby is not taking its feedings well. The fol- 
lowing is a typical formula: 



Weigh the sugar and flour ball and make a paste 
with the barley water. Shake the whole milk, meas- 
ure out 15 oz. in the graduate, and add the barley wa- 
ter mixture. Boil two minutes. Cool in running water, 



PUTTING FOODS TOGETHER 



Whole milk 
Bailey water 
Sugar 
Flour ball 
Boil two minutes. 



15 oz. 

15 oz. 

y-z oz. 

y 2 oz. 



5xGx4 



318 



OBSTETRICS FOR NURSES 



strain bottle and put on ice. The figures at the side 
mean that five feedings of six ounces each are to be 
given at four hour intervals. 

It is necessary to cool all feedings as soon as mod- 
ified, and keep them on ice for preservation until used. 

The only accurate way is to make up the whole quan- 
tity for twenty-four hours, put into separate bottles 
the exact amount of each feeding and give at the time 
ordered, after the bottle has been properly warmed. 
In warming the food, care must be used to get it nei- 
ther too hot nor too cold ; 100° F., or when it feels 
warm to the back of the hand, is about right. The 
child should be held in the arms while taking the bottle. 

A buttermilk feeding must not be heated to more 
than 100° F. because it curdles and can not be used. 

The rubber nipples should be washed thoroughly 
after use, boiled once a day, and kept in boric arid 
solution. 

The necessary articles for home modification of milk 
can be obtained anywhere. One set of utensils should 
be kept for this purpose exclusively and boiled each 
time before the food is prepared. A list is convenient: 

A 10 ounce glass graduate. 

One tablespoon and one teaspoon may be used for measur- 
ing purposes, if unable to get, a satisfactory scale. 
1 2-quart aluminum cooking dish. 
1 long-handled aluminum spoon. 

1 line wire mesh strainer, thirty holes to the inch. 
1 dozen bottles, 5 ounce size if the child is small, and 10 
ounce if the child takes large feedings. 

The bottles should have wide mouths, straight sides, 
and round bottoms, which clean easily. Paper caps or 
corks that fit tightly should be used instead of cotton 
stoppers. Close rubber caps are best, for, as the milk- 
cools, a vacuum is created, the rubber is drawn in and 



INFANT FEEDING 



319 



the milk remains air-tight until opened. If infants are 
kept on a milk diet alone for too long at a time, they 
do not thrive so well, hence as early as six monthg, 
other things may be given. At this stage, the most de- 
sirable additions to the food would be cereal, farina or 
cream of wheat, orange juice, vegetable broth, toast 
crumbs, etc. The administration of orange juice should 
be started when the child is only a few weeks old. 

The quantity of all these foods may be increased as 
the child gets older, and by the end of a year the diet 
is broadened still further. Beside a quart of whole 
milk, it may have thickened soups, vegetables, such as 
cauliflower, spinach, carrots, creamed celery and a lit- 
tle baked potato. Fruits, orange juice, grape fruit 
juice, prune sauce, apple sauce and scraped apple may 
be given, but no bread. In place of bread, use toast, 
Huntley and Palmer wafers and biscuits, and soda or 
oatmeal crackers. Sweet desserts should be avoided, 
but flavored junket or simple custard is unobjectionable. 

No meats are permitted until the child is eighteen 
months old, except, perhaps, a little crisp bacon, or a 
bone to suck. 

None of these supplemental foods should be given be- 
tween meals, but always at the feeding hour. The 
above list supplies a dietary so varied that no child 
will tire of it. 

In reporting the condition of the infant to the physi- 
cian, the following form may be used to advantage. It 
is a clear cut, concise summary of what he wishes to 
know. 

Infant's Daily Report 

1. Food: Does baby take it all? Is he satisfied? 

2. Bowel movements : How many in last 24 hours? What is 
the color? Are they hard, soft, or watery? Any odor? 



320 



OBSTETRICS FOR NURSES 



Any curds? Any slime? Any blood? Any colic? Much 
gas? 

•°>. Does baby vomit? When? How much? 

4. Does baby sleep well? Is he good natured? 

5. Any fever? What is the weight? 

Significant Symptoms and Conditions. — In an artifi- 
cially fed baby, the normal condition of the bowels is 
constipation. The stools are formed, alkaline in reac- 
tion, rather hard, and usually only one a day. 

The stools should have a characteristic color, accord- 
ing to the food taken. Thus: 

Sugar or starch will color the movement a dark brown, 
like vaseline. 

Too much fat gives a pale yellow stool, almost white, 
like putty. 

Eiweiss feedings show as a pale yellow, somewhat like 
the fatty stools, but constipated. 

Barley water gives a brown liquid stool. 

Starvation stools are thin, slimy, dark brown or green. 

The consistency of the movements is also important. 

Too much sugar or starch means diarrhoea, with thin, 
green, acid stools, and much gas and regurgitation, or, 
sometimes foamy, mucous discharges. 

Diarrhoea may also be due to indigestion. Mucus in 
the stools usually signifies intestinal irritation. 

Constipation may exceed the normal limits of the arti- 
ficially fed child when the food contains too much fat. 

Bad odors of the stools result from putrefaction. 

Colic means imperfect digestion with gas. There is 
less colic when the intervals between the feedings are 
lengthened. 

Curds are of two kinds. The soft friable ones due to 
fat, and the hard bean-like masses of protein. Curds 
occur with feedings of raw milk only, and though as- 
sociated with symptoms of indigestion, they signify 



INFANT FEEDING 



321 



overfeeding. If the sugar content of the food is low, 
the child will gain very slowly. 

Vomiting is an important phenomenon. It may be 
due to overfeeding, to excess of sugar or fat in the 
food, or to pyloric stenosis. Excess of fat is shown by 
vomiting and regurgitation of small quantities of food 
one or two hours after feeding. It may be associated 
with constipation. 

If vomiting occurs immediately after feeding, it is 
probably due to the taking of an excessive amount, or 
to the too rapid ingestion of the regular bottle. If the 
vomiting takes place later than twenty minutes after 
feeding, it is probably pathological. It may be the re- 
sult of indigestion, meningitis, or of pyloric stenosis 
(q. v.). 

For the first weeks of life, mother's milk should be 
obtained at all hazards, if possible, but if this is not to 
be had, the artificial feedings may be started. 

A desirable milk modification for the first weeks of 
life should begin with a low food value. For example, 
a child one week old weighing seven pounds, should 
start on a formula like this : 



This will make seven feedings of 2 oz. each, and one 
is given every three hours with one feeding omitted at 
night. 

Cane sugar is less liable to produce colic than sugar 
of milk. 

Lime water, or sodium citrate may be added, if the 
child vomits, or if other indications arise. Both are 
alkalies. 



Whole milk 

Water 

Cane sugar 

Boil two minutes. 



. 7 oz. 
.7 oz. 

V2 oz. 



322 



OBSTETRICS FOR NURSES 



The strength of the mixture, as well as the quantity, 
must be increased as the child gets older and it is seen 
that the formula will agree. 

The percentage of protein is kept down by dilution, 
with plain or cereal water, while fats (as cream) and 
sugars are added to make up the strength lost by the 
dilution. 



CHAPTER XXIII 
CLEANLINESS AND STERILIZATION 

The nurse is called to a case on account of her spe- 
cial qualifications, but also she should lead her patient 
in all things, even in gentility. It is her part to antici- 
pate the Avants of the patient, and regard it as a re- 
proach if the patient has to remind her that it is time 
for food, medicine, bath, or for child to come to the 
breast. Regularity, promptness, and thoughtfulness 
must be supreme. Be on hand when the doctor calls 
and stay until he goes. Be as cheerful as Mark Tapley, 
however dreary the prospect, and do not make noises 
either by the swish of overstarched skirts, the squeak 
of shoes, or the moving of equipment. Above all things, 
the nurse must keep her patient's room, her patient, 
and her own person rigorously clean. She should not 
allow her hands to touch infectious material without 
protection by rubber gloves. This is as necessary for 
her own safety as for the patient and family. Her 
hands should be manicured frequently, her hair sham- 
pooed at short intervals, and her teeth kept in order. 
If the hands get hard, take a teaspoonful of sodium car- 
bonate and one of chloride of lime, mix in the palm of 
the hand with enough water to make a cream, and rub 
well into palms and about the nails. Rinse in clean 
water. (Weir.) 

The nurse's dress should be neat, always mended, and 
carefully adjusted. The nurse who is slovenly in appear- 
ance will be slovenly in her mind and slovenly in her 

323 



324 



OBSTETRICS FOR NURSES 



work. She should not wear her uniform on the street. 
It is bad taste, unprofessional, and unsanitary. 

She should bathe at least three times a week. There 
is always some odor of perspiration about the body, 
and especially around the axillary spaces which are 
filled with hair. Nothing is more offensive and nause- 
ating than being leaned over and waited on by a person 
who has a strong body smell. 

The prodigal use of warm water and soap will aid, 
but there are large sebaceous glands in the armpits and 
their decomposing excretions are retained by the hair 
so lastingly that more radical measures are necessary. 
The axillae should be shaved at least once a month, and 
then the soap and water becomes more efficacious. 
After thorough cleansing, the armpits should be 
dredged with Babcock's Motiya powder, and the an- 
noying and offensive odor will disappear. 

If the patient is a refined and dainty woman, who 
may happen to be afflicted with the same misfortune, 
she will be deeply grateful to the nurse who tells her 
how to get rid of it. 

That some doctors, unfortunately, have strong odors 
about the person — the mixed effluvia of tobacco, alco- 
hol, bad teeth, and uncleanliness — is no excuse for the 
nurse. The doctor should know better, but at all 
events, his offense rarely needs to be suffered more than 
a few minutes at a time, while the nurse is in constant 
attendance. 

The trained nurse should be polite to, but not familiar 
with servants, as she is looked upon as the highest type 
of the professionally educated gentlewoman, and she 
must be constantly alert that her reputation in this 
respect is not diminished. 



CLEANLINESS AND STERILIZATION 



325 



BATHS 

Hot Baths.— Temperature from 98° F. to 120° F. 
Water should be tepid at first and the hot water 
gradually added until the required degree is obtained. 

Warm bath 92° F. to 98° F. 
Tepid 85° F. to 92° F. 

Cold 33° F. to 65° F. 

Sedative Bath. — The patient is stripped and stands 
for an hour in the hydrotherapy room, while a hot 
spray is played up and down the spine. The tempera- 
ture of the water is 104° F. to begin with, and gradu- 
ally increased to the point of toleration. 

An alkaline bath is prepared by adding ail ounce of 
sodium carbonate to each gallon of water. 

Bran Bath. — Add two ounces of bran to each gallon 
of water. Mix the bran in a small amount of boiling 
water and add to the bath water. 

Mustard Bath. — To three gallons of water at a tem- 
perature of 105° F. add a tablespoonful of mustard. 
Leave the child in the water for five minutes, all the 
while rubbing and stroking the limbs and back. Then 
wrap naked in a warm blanket and leave for half an 
hour. 

STERILE DRESSINGS— ANTISEPTIC SOLUTIONS- 
STERILIZATION OF INSTRUMENTS 

The preparation of sterile dressings, antiseptic solu- 
tions and the sterilization of instruments, is particularly 
the work of the nurse, whether in the hospital or in a 
private home. The following directions are therefore 
desirable : 



326 



OBSTETRICS FOR NURSES 



As soon as the nurse is sure her patient is in labor, 
she boils a milk bottle, fills it two-thirds full of 95 per- 
cent alcohol, puts a pledget of sterile cotton in the bot- 
tom and then boils a pair of dressing forceps, which are 
placed, handle up, in the alcohol. (See Fig. 52, page 
132.) With this forceps, she handles all clean dressings, 
instruments, and rubber goods that mug be contaminated 
by touch. 

Dressings and Supplies. — The necessary dressings and 
supplies may be prepared one or two weeks before labor 
according to the following instructions: 

Five Yard Packing. — Draw threads at either end of 
five yard lengths of gauze to its full width. Fold the 
cut edge across until it lies one-third the distance from 
the opposite side. Next, fold the double edge over, and 
bring it to the outside edge of the first fold. Keep it 
perfectly straight. When folded full length, roll from 
the end and wrap in strong muslin Avrappers. Sterilize 
in the autoclave or Arnold sterilizer. 

Pads for the Vidva. — Unroll a whole bale of common 
cotton and cover it with a ¥> inch thickness of absorbent 
cotton. Cut in lengths of 12 in. by 4 in. wide. Cover 
with gauze cut 12 by 14 inches, and fold the ends of 
gauze over absorbent cotton. Roll from the end, wrap 
in paper, seal, and sterilize. 

Pledgets. — Tear two yard strips, lengthwise of the 
roll of absorbent cotton, pull from these, three inch 
pieces, roll them in the hands until round, place in 
clean bags, and sterilize. 

Breast Covers. — Squares of old, soft muslin 4 by 4 
inches, with all strings removed, make the best dressings 
for the nipple. Do not use gauze, because the papillse 
of the nipple may get caught in the mesh and when it 
is taken off, the tender nipple is irritated or abraded. 



CLEANLINESS AXD STERILIZATION 



327 



Breast Binders. — These are made of single material, 
because they would be too warm otherwise. They are 
sleeveless and jacket-shaped and measure 16 inches 
from shoulder to waist, 40 inches long, and 10 inches for 
the arm scallop. A binder of this size, if properly ad- 
justed, will fit a patient of any size. Three will be 
sufficient for the case. 

Abdominal Binders. — The abdominal and breast bind- 
ers are worn during the bed period only. The abdom- 
inal binder is made of unbleached muslin, double ma- 
terial, 14 by 40 inches, and hemmed. In the center of 
the back, on the lower edge, a curved space, six inches 
wide, is cut out to prevent the binder from getting 
soiled. To this curved edge, the pad holder is attached 
by two safety pins, one on either side. The abdominal 
binder is adjusted by pinning firmly above the fundus, 
and loosely below. 

Pad holders are made of unbleached muslin, and meas- 
use 6 by 16 inches. 

Cord Dressings. — Cut squares of surgical lint 4 by 4 
inches, and cut through to the center on one side. 
Gauze may be used, but it is not ideal. 

Nursery Cotton. — Tear absorbent cotton into narrow 
lengths and pull out small one inch pieces. Roll them, 
place in a clean bag and sterilize. 

Applicators. — Use absorbent cotton and toothpicks. 
Tear off small pieces of cotton, moisten the toothpick 
point with water, place in the middle of the cotton, and 
roll firmly. 

Gauze Sponges. — Cut gauze into squares 6 by 6 inches, 
and fold from each side to the center. This brings all 
the ragged edges inside. Fold into squares, place in 
jars, and sterilize. 

Sterilization of Instruments. — Place scalpels in car- 



328 



OBSTETRICS FOR NURSES 



bolic acid 95 per cent for ten minutes. Lift with sterile 
forceps, and put in a basin of 95 per cent alcohol for 
ten minutes. In the absence of carbolic aeid and alcohol, 
the scalpels may be dropped in a 2 per cent solution of 
lysol for twenty minutes. Cleanse with hot sterile 
water. (Do not boil scalpels; it dulls the sharp edges.) 

All other instruments may be placed in a sterilizer 
(dishpan or wash boiler) with enough water to com- 
pletely cover them; boil twenty minutes. Cool in sterile 
pan, which may be set in cold water. Do not use soda 
on the instruments during sterilization, as it makes a 
thick, gummy precipitate on the metal. 

The sterile handling forceps must be immersed at all 
times for two-thirds their length in 95 per cent alcohol. 

Brushes. — After using, all brushes should be thor- 
oughly washed, boiled, and dried, wrapped in waxed 
papers, and sterilized in the autoclave. In the absence 
of the autoclave, boil thirty minutes. 

Basins, pitchers, and douche pans are sterilized by 
WTapping in strong muslin bags and put to boil for 
forty-five minutes in the basin boiler or wash boiler. 
They will not remain sterile longer than one week, even 
when kept in a clean place and well wrapped. Bedpans 
should be washed in a strong solution of soap and water, 
rinsed every morning and boiled for thirty minutes. 

Sterilization of Rubber Goods. — 

Tracheal Catheters. — Drop in a solution of bichloride 
1 : 5000 and leave for twenty minutes. Lift with sterile 
forceps into a basin of warm sterile water and leave for 
ten minutes, or until used. 

Vorhees Bags. — Boil twenty minutes. The bags and 
catheters may be given a longer life by keeping them 
in a 25 per cent solution of glycerine and water when 
not in use. Kerosene vapor is also preservative. 



CLEANLINESS AND STERILIZATION 



329 



Rubber Catheter. — Boil twenty minutes. 

Hot Water Bags, Ice Caps, Rubber Bed Rings. — Soak 
in 10 per cent lysol solution for two hours, wash with 
warm water, and dry thoroughly. The inside of the 
ice caps can be dusted with powder. 

Never leave rubber gloves in a damp place or lying- 
in a solution. It stretches them and weakens the rub- 
ber. To sterilize, they must be washed in a strong solu- 
tion of soap and water, dried, and paired. Then they 
are wrapped in a heavy cloth covering and put in the 
autoclave for twenty minutes. 

Wet Process for Rubber Gloves. — Wrap in gauze or 
cloth and boil for thirty minutes. Lift with sterile for- 
ceps and place in lysol solution 1 per cent until used. 
They are easily drawn on by filling them with the solu- 
tion as the hand goes in. 

The autoclave is not always available, but an Arnold 
or Rochester sterilizer is readily portable, and takes the 
place of the hospital machine. 

Fumigation of rooms is sometimes necessary. Re- 
move all curtains, bed linen, and other washable fabrics 
from the room. Open the drawers of dressers, doors of 
closets, and loosen up and separate everything left so 
the air can get to it. Close the windows and seal the 
crevices with cotton and make the room as air-tight as 
possible. Place a large pan containing six ounces of 
potassium permanganate crystals in the center of the 
room. Pour over this twelve ounces of formalin, close 
and seal the outside doors of the room and leave for 
twelve hours. If the case has been a very septic one, 
it is always a good plan to wash the walls of the room 
before using again. The insides of the drawers and the 
bed should be thoroughly washed with water and green 
soap. A formaldehyde lamp is also quite satisfactory if 
obtainable. 



CHAPTER XXIV 



DIETS AND FORMULAE 

The nurse should serve everything in the most cleanly 
and appetizing way if it is only a cup of tea; and all 
waste, soiled dishes, napkins, and excreta must be re- 
moved as delicately as possible. 

Diet for Pregnancy. — Fresh fish, boiled, broiled or 
baked; and shell-fish raw or cooked, — any way but 
fried. 

Meat, once or twice a day, except when contra- 
indicated by condition of the kidneys. Veal is best 
omitted. 

All farinaceous foods and vegetables may be eaten 
freely. 

Desserts should be plain, but tempting. 

No alcohol is taken without direct permission from 
the doctor, and coffee and tea should be limited. 

Diet for Puerperium. — First two days, milk, butter- 
milk, soup, gruel, cocoa, toast and tea, chicken, oyster 
and clam broth. 

In the next two days, under ordinary conditions, the 
diet is increased and made somewhat heavier. 

Semisolids are added like milk-toast, eggs, poached 
or boiled soft, oysters, clams and boiled fish. 

After the milk comes in, the woman is put on a 
general diet as fast as she can digest it. 

Farinaceous diet — melons and oranges. — 

Breakfast. — Cereal, coffee with milk and sugar, if de- 
sired, bread and butter, corn bread, rolls, toast, muffins, 
hominy, cereal with cream. 

330 



DIETS AND FORMULAE 



331 



Lunch. — Vegetable soups, bread, butter, potatoes, 
beans, rice, macaroni and cereal, peas, buttermilk, pud- 
ding, such as rice, tapioca, bread cornstarch, jellies, 
fruit juices, pumpkin, squash, turnips, tomatoes, etc. 

Dinner. — Bread, butter, milk-toast, hominy, rice, 
celery, fruit salads, lettuce, apples, pears, prunes, stewed 
fruits or fresh melons, etc. 

The following diets are routine at many hospitals: 

General Diet. — Full tray of food in season as fur- 
nished by the hospital. Three meals daily. 

Light Diet. — Foods from the following list may be 
selected, and served three or five times daily, as de- 
sired : 

Soups of all kinds. When leguminous foods are em- 
ployed, their outer coverings must be removed by rub- 
bing them through a sieve or colander. 

Vegetables of all kinds, except green vegetables (pro- 
vided they have been reduced to a pasty consistency). 
Those with excess of fiber or cellulose, such as turnips, 
celery, asparagus, and cabbage, should be chopped after 
thorough boiling, then mashed, while those having tunics 
should be sieved or colandered. 

Grain foods of all kinds thoroughly cooked, excepting 
corn preparations containing much cover, as hulled 
corn. 

Prepared foods such as tapioca, macaroni, and vermi- 
celli, require prolonged cooking. 
Meats, scraped beef. 
Eggs, soft boiled, raw or soft poached. 
Bread of all kinds, stale, homemade. 
Puddings, ices. 

Beverages, all kinds unless otherwise ordered. 
Forced Diet.— This includes the general diet with the 
addition of one quart of whole milk and four eggs. The 



332 



OBSTETRICS FOR NURSES 



milk may be given plain or as an eggnog at seven, ten, 
three, and eight o'clock. The eggs may be given raw 
or cooked soft in any form. 

Milk Diet. — Twelve ounces of whole milk (375 c.c.) 
may be given every two hours; i. e., at six, eight, ten, 
twelve, two, four, five, and eight o'clock, or the patient 
may sip it at her pleasure. 

The milk may be given raw, boiled, diluted with plain 
water, lime water, Vichy, seltzer, or Apollinaris to taste. 
The daily amount should include three quarts of Avhole 
milk. Koumiss, buttermilk and milk soups are sometimes 
allowed. Note the exact amount taken, and give reasons 
for failure. Watch the stools for undigested milk. 

Liquid Diet. — Whole milk, buttermilk, koumiss, beef 
tea, or beef, chicken, mutton, oyster, or clam broth, in 
eight ounce portions, or two ounces of beef juice, every 
two hours. Lemonade, orangeade, ice cream, or fruit 
ices, at intervals and amounts as desired. 

Ulcer Diet. — Whole milk and cream, equal parts, 
three ounces every two hours. Sodium bicarbonate, 
thirty grains, in a small amount of water, to be given 
before and thirty minutes after feeding. Albumin 
water, soft boiled eggs, scraped beef, custard, and cream 
soups to be added later by direction of the physician. No 
seasoning except salt is allowed. 

Prochownik Diet.— This diet is advised where some 
necessity exists for preventing a large child. It is ad- 
ministered in the last six weeks of pregnancy only. 

Breakfast. — Small cup of coffee, two slices of toast 
(1 ounce). 

Lunch. — Small piece of meat, fish or an egg, a little 
sauce. A vegetable prepared with fat, lettuce, a small 
piece of cheese. 

Dinner. — Same as lunch with three slices of bread and 
butter, and a little milk. 



DIETS AND FORMULAE 



A pint of water daily is allowed; taken in sips it lasts 
longer. 

Soup, water, beer (all fluids) and sugar, pastry, and 
potatoes are forbidden. 

Skimmed Milk Diet (Karell). — Skimmed milk, to 
which a pinch of salt is added, 3 to 6 ounces, three 
or four' times daily, increasing the amount gradually, 
taken slowly to allow thorough mixture with saliva, 
warmed in winter, room temperature in summer. 

Acute Nephritis Diet. — Whole milk, 1000 c.c. ; cream, 
250 c.c; Avater, 150 c.c; stewed fruit, well sweetened, 50 
c.c. 

Bread, well buttered, may be toasted, 150 gm. (equal 
to three slices) 150 gm. 

Green salad of lettuce, celery, apple, pear or grape 
fruit, and served either with olive oil, or with a mayon- 
naise dressing made from olive oil, egg and lemon juice, 
with salt (but no pepper or condiments) may be given 
in two small portions daily. 

Cooked cereals (cream of wheat, etc.) with cream and 
sugar, one portion equal to about two ounces, once daily. 

The above represents a daily fluid intake of about 
1500 c.c. The diet is to be given in " three meals," at 
eight, one, and six o'clock, with fluid nourishment at 
eleven, three, and nine o'clock. 

RECTAL FEEDING 

Nutrient enemas should be given every six hours, un- 
less otherwise ordered. It is necessary to cleanse the 
lower bowel with a saline or soapsuds enema at least 
once a day. The cleansing enema should be given one 
hour before the nutrient enema is to be given. The 
proper quantity for the nutrient enema is four to six 



334 



OBSTETRICS FOR NURSES 



ounces for an adult, and one to three ounces for a child. 
Nutrient enemas should be given slowly at very low 
pressure, the level of the fluid in the can being not over 
eight to ten inches above the level of the rectum. If the 
injected material is thick, a piston syringe may be re- 
quired. The patient should be placed upon the left side 
with the hips well elevated and should be kept in that 
position for fifteen to twenty minutes after the enema 
has been given. The tube should be oiled and not be 
inserted more than three or four inches. The tempera- 
ture of the enema should be about 98 degrees. If there 
is a strong tendency to evacuate the enema, pressure 
should be made against the rectum with a pad. 

The following nutrient enemas may be ordered by 
name. 

Glucose Enema. — Glucose (dextrose, grape sugar) 1 
ounce, normal salt solution 5 ounces. 

The glucose should first be dissolved in hot water. 
The amount of glucose may be increased, upon order, if 
no irritation is produced. 

Pancreatinized Milk Enema.— Add 1 tube of peptoniz- 
ing powder, or 1 to 2 drams of "Pancreatic solution" 
to 1 pint of skimmed milk. Stir well and place in a 
warm water bath for one-half hour. Add 1 dram of salt. 

Milk and Egg Enema.— Thoroughly beat the whites 
of 2 eggs, add 1/3 dram of salt, and 6 ounces of skim- 
med milk. Add one tube of peptonizing powder, or 1 
to 2 drams of "pancreatic solution," stir well, and 
place in a warm water bath for one-half hour. 

Milk, Egg, and Beef Juice Enema.— Mix the beaten 
whites of 2 eggs, 2 ounces of fresh beef juice, 6 ounces 
of skimmed milk, and 1/3 dram of salt. Add 1 tube 
of peptonizing powder, or 1 to 2 drams of "pancreatic 
solution," stir well, place in a warm water bath for 
one-half hour. 



DIETS AND FORMULAE 



335 



Milk and Glucose Enema. — Add 1 tube of peptonizing 
powder to 6 ounces of skimmed milk, stir well, place in 
a warm water bath for one-half hour. Add 3 drams of 
glucose and 1/3 dram of salt. 

ELIMINATIVE ENEMAS 

Impaction Enema. — 

Castor oil or olive oil, 1 ounce. 

Soapsuds (100° R), 1 quart. 

Mix as thoroughly as possible, add one 
dram of spirits of turpentine beaten up 
with the yoke of one raw egg. 
S. S. and G. Enema. — 

Soapsuds, 1 quart. 

Glycerine, 1 ounce. 
Asafcetida Enema. — 

Milk of asafcetida, 8 ounces. 

Water, 8 ounces. 

1-2-3 Enema. — 

Magnesium sulphate, 1 ounce. 
Glycerine, 2 ounces. 
Water, 3 ounces. 
Milk and Molasses Enema. — 

Milk, ordinary cooking molasses in equal parts, possibly 
8 ounces of each. Heat, but do not boil. 

Turpentine Enema. — 

Soapsuds, 1 pint. 

Turpentine, 1 dram. 

It acts quickly and effectively. 

All enemas should be given through a colon tube. 
The patient should be on the left side and the tempera- 
ture of the injection should be about 100° F. 



336 



OBSTETRICS FOR NURSES 



DIET LIST 

Albumin Water. — Take Avhite of 1 egg, stir until 
separated. Add a little lemon juice and 1 pint of water. 
Ice and serve. Sugar or salt may be used. 

Barley Water.— Wash 2 ounces of barley with cold 
water. Boil for 5 minutes in fresh Avater. Strain. 
Then cover with 2 quarts of water and cook slowly down 
to 1 quart. Flavor with thinly cut lemon rind and 
sugar. Do not strain unless patient requests. 

Beef Juice. — Cut into cubes l]/ 2 inches each, 1 pound 
round steak. Place in a clean, ungreased pan, and fry 
one and one-half minutes on each side. Pour into hot 
meat press and apply pressure. In absence of a press, 
a potato ricer may be used. Season with salt and pep- 
per. May be served iced or heated by putting in double 
boiler and stirred all the time. Do not allow to curdle. 

Beef Tea. — Put 1 pound of finely chopped round steak 
into a quart glass jar, fill with cold water. Place jar in 
kettle of warm water. Leave over slow fire for four 
hours. Strain, season with salt and pepper. 

Champagne Whey. — Boil 8 ounces milk for fifteen 
minutes. Strain through cheesecloth. Add iy 2 ounces 
champagne. 

Chicken Broth. — Skin and chop in small pieces one 
small or one-half large fowl. Boil bones and all with 
one blade of mace, a sprig of parsley, and 1 table- 
spoonful of rice, 1 crust of bread and 1 quart of water, 
for one hour. Skim from time to time. Strain through 
coarse colander and season to taste. 

Cinnamon Water. — One-half ounce stick cinnamon. 2 
cups boiling water. 

Break sticks in small pieces. Add water, boil twenty 
minutes. Strain and serve hot or cold. 



DIETS AND FORMULAE 



337 



Clam Broth. — Wash thoroughly (j large clams in shell. 
Put in kettle with 1 cup of cold water, bring slowly to 
boil, and keep temperature for one minute. Pour off 
broth and serve hot. Add salt and pepper. 

Eggnog. — Beat an egg, white and yolk separately. 
Add to the yolk 1 dram of vanilla extract, a pinch of 
salt and 4 oz. fresh milk, and 1 dram of sugar. Add y 2 
dram of sugar to white of egg, stir a portion into the 
glass and heap remainder upon top of glass. 

Egg - Cordial. — One egg white, 1 teaspoon sugar, 1 
tablespoon brandy, 2 grains salt, 2 tablespoons cream. 

Beat white until stiff. Add cream, continue beating, 
add other ingredients, and serve cold. 

Egg Lemonade. — Beat 1 egg and 1 teaspoonful of su- 
gar until very light, add Vi ca ^ e °f yeast dissolved in 
one-fourth cup of water, two tablespoonfuls of sugar, 
pour into bottles with patent stopper, fill bottles only 
two-thirds full, cork tightly. Shake well. Allow to 
stand on ice twenty-four hours. 

Flaxseed Tea. — One ounce of whole flaxseed, 1 ounce 
powdered sugar, y 2 ounce licorice root, 1 ounce lemon 
juice. Pour over these materials 1 quart of boiling 
water and allow to stand four hours. Strain off liquor. 

Gum Arabic Water. — Dissolve 1 ounce of gum arabic 
in 1 pint boiling water. Add y 2 ounce sugar, a wine- 
glassful of sherry, and juice of one lemon. Serve with 
ice. 

Junket. — Take z / 2 pint of fresh milk in a saucepan. 
Add 1 teaspoonful of essence of pepsin, stir just enough 
to mix. Pour into custard cups. Let stand until 
firmly curded. Serve plain or with grated nutmeg. 
Sherry may be added. 

Koumiss. — Heat four cups of milk, then cool; when 
lukewarm, add Vi cake of yeast dissolved in one-fourth 



338 



OBSTETRICS FOR NURSES 



cup of water, two tablespoonfuls of sugar, pour into 
bottles with patent stopper, fill bottles only two-thirds 
full, cork tightly. Shake well, allow to stand on ice 
twenty-four hours. 

Milk Shake. — White of 1 egg, 1 ounce sugar, 1 ounce 
chipped ice, 1 ounce cream. Shake in milk shaker two 
minutes. Add milk to fill glass. Flavor with vanilla 
and lemon. 

Mutton Broth. — Boil slowly \]/ 2 pounds of lean loin 
mutton, including the bone. Add a little salt and Y?. 
onion. Pour broth into a basin. Skim off fat Avhen cool. 
Warm as used. 

Oatmeal Gruel. — One teacup oatmeal flakes, cover with 
1 quart cold water. Place on slow fire and soak three 
hours. Strain, add 4 teaspoonfuls of sugar and 1 tea- 
spoonful of salt. 

Oatmeal Water.— Cover 1 teacupful oatmeal with 1 
quart cold water. Let it stand two hours. Stir often. 
Strain. Serve with salt, sugar and ice. 

Peptonized Milk. Warm Process.— Dissolve the con- 
tents of Fairchild 's peptonizing tube in 4 tablespoonfuls 
cold water. Add to 1 pint of milk. Put in glass jar, and 
place jar in vessel of warm water. Heat slowly to 115° 
F. Stir slowly and allow it to remain thirty minutes. 
Place on ice at once to check further digestion. 

Peptonized Milk. Cold Process. — In a clean quart 
bottle, put one peptonizing powder (Fairchild). Add 1 
teacupful of cold water. Shake. Add 1 pint fresh cold 
milk. Shake well. Place on ice. Do not heat before 
using. 

Rice Water.— Pick over and wash 2 tablespoonfuls of 
rice. Put in a saucepan with 1 quart of boiling water; 
simmer two hours. When rice is dissolved, strain. Add 



DIETS AND FORMULAE 



339 



teaspoonful salt. Serve warm or cold. Sherry may be 
added. 

Rum Punch. — Two teaspoonfuls powdered sugar, 1 
egg well beaten, warm milk, 1 large wineglassful ; 4 
ounces Jamaica rum. Flavor Avith nutmeg. 

Scraped Beef. — Place on breadboard a round steak. 
Scrape with tableknife but do not take any shreds of 
muscle. Salt and pepper. Spread on thin slices of bread. 
Place in toaster until seared. 

Toast Water. — Three slices of stale bread well browned, 
but do not burn. Put in a pitcher, pour over them 1 
quart boiling water. Cover closely, and allow to stand 
until very cold. Strain. Wine and sugar may be added, 
to stimulate. 

Wine Whey. — Put 1 quart new milk in a saucepan and 
place over fire. Stir until nearly boiling. Add 2 ounces 
of sherry wine. Boil slowly for fifteen minutes. Skim off 
curds as they arise. Add 1 tablespoonful sherry. Skim 
again, then strain through gauze. 



CHAPTER XXV 



SOLUTIONS AND THERAPEUTIC INDEX 

Acid, Boric. 5 dr. in a pint of water makes a 4% solution, or 
1:25. 

Acid, Carbolic. 15 In. in a quart of water makes a 0.1% solu- 
tion, or 1:1000. 5 dr. to the quart makes a 2% solution; 
and 1V4 oz. to the quart, a 5% solution. 

Chinosol. 15 gr. to the quart of water makes a solution of 1:1000. 

Formalin. 1 dr. to the quart of water makes a solution of aboul 
1:500. 

Mercury Bichloride. 15 gr. to quart of water makes a 0.1% 
solution, or 1:1000. 1% gr. to the quart makes a 0.01% solu- 
tion, or 1:10,000. 

Normal Salt Solution. 2 dr. of salt to the quart of water, or 
0.9%. 

Physiological Salt ' Solution. Take normal salt solution as given 
above and to every 3% oz. add 15 gr. of carbonate of soda. 

Potassium Permanganate. 2% dr. to the quart makes a 1% 
solution. 3 gr. to the quart makes a 1:5000 solution. 

Silver Nitrate. 4y 2 gr. to the ounce of water or 1 gr. to 1-7/10 
dr. makes a 1% solution. 

Ziratol. 2%% teaspoonfuls to a quart of water makes a ^ f ', 
solution. 

For general reference the following valuable table is appended: 



SOLUTIONS 



341 



H 5 

z S 
o - 



1 :5000 


0.05 
009 
0-18 
027 
036 
0.46 


1 :4000 


cd cm co co t- 

O H N CO iC 

© © © © © © 


1 :3000 


© t-i co ^< co t- 
o o o o © o 


c 
o 
o 

CM 


CM CO CD 00 ^ 
i-h CM ^ CD OS iH 

O O O O O iH 


o~~ 

o 

o 


CM i-h CM 00 
N Tf O) CO 00 M 

O O O pH iH CM 


1:500 


^ S oo t» S w 

© © H CM CO "CP 


65 

Q 

m 


CM ~ "3 
O CM 

r-1 04 lO t- *H iH 
iO © © © CM »C 
i-H 00 CD OS i-H i-H 


65 
ua 

CM 


LO o o O © O 
CO CO CD OS CM Hi 
CM CO lO CD 


65 

o 

CM 


CM CO CD CM Hi 

°> O O o o © 
CM CO ^ Hi 


65 


00 lO Hi Hi 

to eo t* o 3 & 
* ^ 3 Sm cm CO 


65 

o 


LO 

OS GO t- CD 

OS 

t- CO H M 
O] T v) ^ ^ ^ 


65 

00 


OS 00 t- CD Hi 

S3 lO CO »H OS 
i— i CO t- »-* ^ oo 


1 CP 


H Ol T? CD CO 

00 CD CM 
,-H CM Hi 00 



C o 

O J> 
3 "3 



"5 u 






N 


N 


N 


N 


.a ** 
H • 13 
3.S 


o 


0 


O 




o 










c 






CM 


CO 




U5 





342 



OBSTETRICS FOR NURSES 



THERAPEUTIC INDEX 

Young's Rule for Dosage: The age of the child is di- 
vided by the age of the child plus 12, and the result is the 
appropriate dose for the child. The doses given below 
are for the adult unless otherwise specified. 

Absorbent. A medicine or dressing that promotes absorption, 

such as potassium iodide, Tr. iodine, glycerine, or hot 

vaginal douches. 
Adrenalin. The blood-raising principle of the suprarenal 

glands. It is haemostatic and astringent. Acts somewhat 

like digitalis on the heart. 

Uses. — Vomiting of pregnancy, increased glandular activity, 
haemorrhage, inflammation of mucous membranes. 
Dose. — Internally, 5-10 m. of the 1:1000 solution. Extern- 
nally, the solution of 1:1000 or 1:10,000 may be applied. 

Albolene. An oily white substance obtained from petroleum. It 
is used on the nipples and skin of the mother and to remove 
the vernix caseosa from the skin of the child. 

Aloin, Strychnia, and. Belladonna. A laxative pill which usually 
contains aloin 1/6 gr., strychnia sulph. 1/60 gr., and Bella- 
donna 1/12 gr. 

Ammonia Carbonate. Antispasmodic, stimulant, and expecto- 
rant. 

Uses. — Stimulant to heart. Stimulating expectorant in pneu- 
monia and bronchitis. 

Dose. — 5-20 grains in mucilage or syrup. 

Anaesthone. A mixture of adrenalin chloride (0.1%) and chloro- 
tone (5%) in an ointment base of wool fat and petrolatum. 
Astringent, antiseptic, anesthetic and germicide. Useful ap- 
plication to swollen mucous membranes or in coryza. 

Argyrol (Silver Vitellin). Antiseptic and germicide. 

Uses. — Like Silver Nitrate, but less irritating to the tis- 
sues. 3-5% solution in water is an injection for gonorrhoea. 
15% solution dropped in the eyes of the new-born may pre- 
vent ophthalmia. 25% solution may be used twice a day 
as a remedy for existing ophthalmia, but the strength should 
be reduced after three or four days. 10-15% solution is 
used as an injection in cystitis. An ounce or more of the 
solution may be left in the bladder until the next evacuation. 

Asafcetida. A fetid gum resin. Carminative, antispasmodic, 
mild stimulant, and expectorant. 

Uses. — Gas pains of adults and infants. Hysteria and in- 
digestion. 

Dose. — 5-10 gr. t.i.d. For infantile colic, an emulsion called 
the mistura of asafoetida may be used in 2-4 dram doses. 
For adults 1-2 tablespoonfuls. 



THERAPEUTIC INDEX 



Belladonna. Nervine, mydriatic, sedative, narcotic, antispas- 
modic and anodyne. Makes the throat dry and dilates the 
pupils. 

Uses. — Night sweats, nervous cough, pain, incontinence of 
urine and to restrain glandular activity. 
Dose. — Fl. ext. 1-3 Tn_ ; dry ext. V 2 -l gr. Tincture 8-20 1u_. 
Solid ext. y^-Vi gr. AH for adults. For infants, proportion- 
ately less. See Bule for Dosage. 
Benzoin. Antiseptic and externally a styptic and protective for 
sores. 

Uses. — Sore nipples and urticaria. Lard is also benzoin- 
ated for use in removing vernix caseosa. Compound Tr. of 
benzoin contains, benzoin, purified aloes, storax, balsam of 
Peru, and alcohol. 
Benzoinal, Albolene mixed with benzoin. 

Bismuth Subnitrate. A white heavy powder. Antiseptic and 
astringent. 

Uses. — Subacute gastritis, pyrosis, diarrhoea and vomiting of 
pregnancy. Particularly desirable in infancy because it is 
free from arsenic, lead and silver. 
Dose. — 5-60 gr. in the adult. 
Boric Acid (Boracic Acid). A white crystalline powder. Anti- 
septic. 

Uses. — As a dressing and lotion for eyes, navel, mouth, nip- 
ples, and all mucous surfaces. In solution to preserve the 
sterility of rubber nipples until they are needed. 
Dose. — Internally, 5-15 gr. Solutions are usually about 4% 
or 5%. A saturated solution in water is about 6%. In hot 
water 25%. 

Boroglyceride. An antiseptic paste of boric acid and glycerine. 
When an excess of glycerine is present the preparation is 
called boroglyeerol. 

Uses. — An oxydizer in endometritis. It is applied to the 
cervix on cotton tampons. 
Calcium (Lime). Stomach sedative, soothes the irritated or 
burned skin, corrects hyperacidity, increases the clotting 
power of the blood (?). 

Lime water is a saturated solution of calcium hydrate and 
is used for nausea, to break up the curds of milk, and to 
increase its digestibility. It is mildly constipating. 
Calomel. See Mercury. 

Camphor. A solid volatile oil. Nerve sedative. Anaphrodisiac. 
Antispasmodic. Stimulant. 

Uses. — The monobromated camphor is given internally for 
hysteria, neuralgia, and as a hypnotic. 
Dose. — 1-10 gr. 

Camphorated Oil. A solution of camphor in cottonseed oil. Kube- 
facient and stimulant. 

Uses. — Internally in collapse. Externally as an application 
to the child for colds of chest and nose. 



344 



OBSTETRICS FOR NURSES 



Dose. — 5-20 TIV hypodermically in collapse. The injection 
should be made deep into the muscle. 
Carbolic Acid (Phenol). Derived from coal tar. Antiseptic 
deodorant and local anaesthetic. 

Uses. — Vomiting of pregnancy, pruritus, eczema, steriliza- 
tion of instruments. Usual solution is 2 1 /%% to 5%. For 
sterilization of knives, scissors and other sharp instruments 
the 95% is used. In pruritus, the following wash will aid: 
carbolic acid, 12 dr., glycerine 2 dr., alcohol, 4 3 water q.s. 
1 pt. Apply. 

Cascara Sagrada. Stimulant laxative, and cathartic. Useful in 
pregnancy, but after labor there is evidence that it may 
go over in the milk to the child. 

Dose. — Fl. ext. 10-20 u\. The Hinkle pill contains cascara. 
Castor Oil. Oil expressed from the seeds of the castor plant. 
A cathartic. Acts in four or five hours. 

Dose. — For adults, % oz. to 1 oz. For infants 10 to 60 drops 
given with a dropper — not with a spoon. 

Castor oil cocktail. — Rinse out. the glass with lemon juice 
or whiskey. Pour in teaspoonful of lemon juice and a 
teaspoonful of whiskey, add castor oil in amount required, 
cover with whiskey and give. 

A paste is made from the mixture of castor oil and bismuth 
subnitrate in equal parts, which is an excellent prepara- 
tion for sore nipples. 
Cerium Oxalate (and Cerium Valerianate). Sedative and nerve 
tonic. The oxalate is a white crystalline powder, odorless 
and tasteless. 

Uses. — Vomiting of pregnancy, seasickness. 
Dose. — 2-10 gr. several times daily. 
CharcoaL Administered in tablet form or as a powder between 
two slices of buttered bread. 
Uses. — Acid stomach. Vomiting of pregnancy. 

Chinosol. Nonpoisonous, nonirritating and odorless. Antiseptic 
deodorant, styptic and analgesic. Dissolves instead of coagu- 
lates secretions. 

Uses. — Antiseptic solutions for hands and sponges, deodoriz- 
ing wash for vagina post partum, intrauterine douche, wash 
for gonorrhoea and cystitis. 

Dose. — For douche or hand solution 1:1000 or 1:5000. For 
dusting powder, 1 part to 10 or 20 of starch, talcum, borie 
acid, or bismuth subnitrate. 

Chinosol will corrode unplated steel. It may be mixed with 
salt, but not with soap. 
Choral Hydrate. White crystal masses. Pungent in odor and 
taste. Hypnotic, antispasmodic, antiseptic and analgesic. 
Uses. — Insomnia, eclampsia, convulsions, and to restrain se- 
cretion of milk. 

Dose. — By mouth, 10-30 gr. By rectum, not to exceed 60 gr. 
In infants 1-2 gr. by rectum in an ounce of water. 



THERAPEUTIC INDEX 



345 



Chymogen. A preparation of rennin (10%) made by Armour & 
Company. 

Coagulen Ciba. A physiological nontoxic styptic, prepared from 
the natural coagulents of the blood. A 10% solution in 
water will hasten the beginning and end of coagulation. 
May be applied to bleeding surfaces directly, or given under 
the skin, into the muscle, or into a vein. 3 : %% to 5% solu- 
tion in distilled water, should be sterilized by boiling 2-3 
minutes. Do not filter. Inject. 

Cocaine Hydrochlorate. Anaesthetic, sedative, anodyne, anti- 
pruritic. 

Uses. — Vomiting of pregnancy, with caution. 

Dose. — Internally %-l% gr. Externally a 4%-10% solution 

in water. 

Codeine. Alkaloid of opium. Less narcotic than morphine. 

Uses. — After-pains and pain of over-distended breasts. 

Dose. — Vi-^ 1 /'! gr. by mouth. %-% gr. hypodermically. 
Compound Licorice Powder. See Senna. 
Condylomata. 

Use— 

R Acid. Salicyl. gr. x 

Acid Boric. gr. xxx 

Calomel. 3 i 

M. 

Sig.: Apply twice daily. 
Digitalis. Cardiac tonic. Diuretic. Stimulant. 
Uses. — Weak heart. Syncope. Collapse. 

Dose— For adult: of the tincture, 5-15 Tl\, fl. ext. 1-3 TTL, 
ext. gr. %-V 2 . 

Digipuratum. A preparation of digitalis from which the inac- 
tive substances have been removed. It is used in the same 
conditions as digitalis. 

Dose. — The tablets contain IV2 gr. and one is given four 
times daily until ten are taken. Then stop. Hypodermic- 
ally. Each viol contains 1 c.c. of fluid and equals 1% gr. 
of "digipuratum. Each dose contains enough of the active 
principle of digitalis to kill a 30 gm. frog. 
Ergot (Fungus of Bye). Contracts unstriped muscle fiber. 

Uses. — To check haemorrhage after labor. To promote in- 
volution. Must not be given in labor until the uterus is 
empty. 

Dose. — By mouth 15-60 IT), of the ft. ext. Hypodermically, 
10-20 TTL- 

Ergotole, Ergotine. Concentrated solutions of ergot, 2% times 
as strong as the fluid extract. They are sterilized and 
preserved in glass ampoules. 
Uses. — See Ergot. 
Dose— 30-60 TT\_. 

Green Soap. A soap made of linseed or other oil, potash, alco- 
hol and water. 



346 



OBSTETRICS FOR NURSES 



' ' The adoption by the U. S. Pharmacopoeia of the term Sapo 
Viridis (green soap) is unfortunate, since soft soap even 
if made from green hempseed oil will become brown-yellow 
unless artificially colored." — U. S. Dispensatory. 
Haemophilia. A condition of the blood wherein its clotting 
power is diminished or absent. 

Coagulen, horse serum, or diphtheria antitoxin may be 
given hypodermically. Direct transfusion of blood from 
another is best. 

Hyoscine, Morphine, and Cactin. (H. S. & C. Tablets). A pro 
prietary combination of drugs. The action is said to be 
similar to that of morphine and scopolamine. 

Iodine, Tincture. 

Uses. — To sterilize the skin before operation. In vomiting 
of pregnancy it is sometimes effective. Drop doses may 
be given well diluted. Externally it is applied to ulcers, 
as in Bednar's disease, and sometimes as a dressing for 
the cord. In pruritus vulva; it is a valuable application. 

Iron. Tonic emmenagogue. 

Uses. — To increase the number of red blood corpuscles. To 
raise blood pressure and to increase the secretion of milk. 
Dose. — 3-5 gr. Blaud's pill contains the carbonate in a form 
that is easily assimilated. 

Laxatives. Laxatives are unirritating and excite moderate 
peristalsis. Sulphur, magnesia, cassia, manna, cascara 
sa^rada, the Hinkle pill, and the A, B & S pill are usually 
mild in action. 

Lysol. Disinfectant and antiseptic for hands and instruments. 
It is a brown syrupy fluid made from coal tar oil, which is 
distilled and mixed with fat, soap, etc. It has a creosote 
odor and contains 50% cresol. Readily soluble in water. 
Prepared in %-4% solutions. 

Magnesia, Calcined. Antacid and cathartic. Comes in white 
cakes. 

Uses. — Acid stomach, vomiting of pregnancy, ' '.heartburn, " 
and constipation. 
Dose.— 30-120 gr. 
Magnesia, Milk of. A mixture of magnesia and water. Has the 
same properties as the above. 

Dose. — For adults, 2-3 teaspoonfuls. For infants, \i-2 tea- 
spoonfuls. 

Magnesia Sulphate (Epsom Salts). Saline cathartic. 

Uses. — The profuse watery stools produced by magnesia are 
vahiable aids to elimination when the kidneys are over- 
worked or defective. In congestion of the breasts and 
threatened eclampsia, or in any case where it is desirable 
to drain off waste or dehydrate the system. 
Dose. — 1 teaspoonful daily in hot water before breakfast. 
V2-I oz. as a single dose or 1 oz. by rectum, as in the 1-2-3 
enema. 



THERAPEUTIC INDEX 



347 



Menthol (Mint Camphor, Japanest Peppermint). Analgesic, anti- 
septic, anaesthetic, and vascular stimulant. 

Uses. — In pruritus vulvae, yomiting of pregnancy, and haemor- 
rhoids. 

Dose. — By mouth 3-5 gr. In tampons, one part to five of 
oil. In ointments one part to sixteen. To the vulva for 
pruritus, use the spirits in 5% solution. 
Mercury (Hydrargyrum). Cathartic, alterative, antisyphilitic, 
antiseptic and disinfectant. Readily absorbed by the un- 
protected mucous surface and relatively inert when the 
membrane is covered by a discharge. Solutions of the bi- 
chloride when used as a lotion unite with the albumin of 
a mucous discharge and form an albuminate of mercury, 
which is inactive. Bichloride solutions have small place in 
obstetrics. They are hard on the hands and destructive to 
instruments. Other agents like lysol, ziratol and chinosol 
have satisfactory germicidal properties and in addition are 
nonpoisonous, lubricative and cleansing. 

Mercury should only be given to the infant in the form of 
calomel (the mild chloride). The dose is YvrV* gr-, repeated 
if necessary. 
Morphine. Alkaloid of opium. 

Antispasmodic, hypnotic, analgesic and narcotic. 
Uses. — To relieve pain, produce sleep, check diarrhoea, and 
to control the pain, as well as the contractions of abortion. 
To relax a rigid os. 

Dose. — In "Twilight Sleep" and rigid os the first dose is 
Morph. sul. Yq-M gr. and scopolamine Hydrobromid 1/200- 
1/150. The scopolamine to be repeated if required, in one- 
half or three-quarters of an hour. The usual dose of mor- 
phine hypodermically is g r - 

Nitroglycerine (Glonoin). Vasomotor dilator, arterial stimulant. 
Uses. — For the prostration following haemorrhage. 
Dose. — 1/200-1/50 gr. hypodermically. 

Novocaine. Local anaesthetic, similar to cocaine, but less toxic. 
For local anaesthesia in solutions of 0.25% to 2% usually in 
association with adrenalin (5-10 drops of the 1:1000 solu- 
tion to each 10 c.c. of novocaine solution). 

Nux Vomica. The plant from which strychnia is derived. Tonic, 
stomachic, and stimulant to muscle, nerve, and heart. 
Tj ses . — Bitter tonic and stimulant. Vomiting of pregnancy 
and agalactia. 

Dose. — Ten drops of the tincture in water before meals. 
Opium. The concrete juice of the poppy. Relieves pain. Con- 
stipates. 

jj ses , — Haemorrhoids in adults, colic and diarrhoea in infants. 
j) ose . — One grain in suppository night and morning for adult. 
For infant, as paragoric only. Two to five drops only, not 
repeated. Children bear opium badly. 



348 



OBSTETRICS FOR NURSES 



Pepsin. A ferment in the gastric juice that digests proteins. In 
commerce it is obtained from the pig. 
Uses. — Imperfect digestion. 
Dose. — For adult, 10-15 grs. For infant, 2 gr. 

Phenolphthalein. A nonofficial coal tar derivative. Mild laxa- 
tive. 

Dose. — 2-3 gr. Phenolax and chocolax are preparations of 
the drug. 

Pituitary Extract (Pitvitriv). A substance derived from the 
infundibular portion or the posterior lobe of the hypophysis 
cerebri. Nontoxic, stimulant to unstriped muscle. 
Uses. — Uterine inertia, post partum haemorrhage, Cesarean 
section and tympany. Will not produce abortion nor pre- 
mature labor. May be tried in acute anaemia to raise the 
blood pressure. 

Dose. — 5-15 TTV . Repeated if necessary. 
Potassium (or Sodium) Bromide. White granular powder. Sol- 
uble, 1 to 5 in water. Sedative, hypnotic, antiepileptic. 
Uses. — Neurasthenia, convulsions, nymphomania, vomiting of 
pregnancy. 

Dose. — 20-60 gr. In enema with chloral. Pot. bromide 40 

gr. and chloral 20 gr. in several ounces of water or milk. 
Potassium Iodide. Alterative emmenagogue. Uric acid solvent. 

Uses. — Syphilis rheumatism, swellings, slow inflammations, 

excessive secretion of milk. 

Dose. — 2-10 gr. increased as required. 
Potassium Permanganate. Dark purple opaque prisms. Soluble 

in water 1 to 16. Disinfectant, deodorant, antiseptic, 

astringent. 

Uses. — As an injection in leucorrhcea and gonorrhoea, 1:5000 
solution. 

Purgatives. Simple purgatives produce free discharges from 
the bowels with some griping. Senna, aloes, rheubarb, castor 
oil, and calomel are examples. Saline purgatives are fol- 
lowed by profuse watery evacuations. Magnesia sulphate, 
and citrate, potassium and sodium tartrate, and sodium 
phosphate belong to this class. 

Drastic purgatives bring about a violent action of the bowels 
with much griping and tenesmus. Such are jalap, colocynth, 
elaterium, and croton oil. Hydrogogue purgatives combine 
the results of the salines and drastics. They have much 
griping with profuse watery stools. The hydrogogues are 
elaterium, gamboge, croton oil, and potassium bitartrate. 
Quinine Sulphate. (Derived from Cinchona bark.) Antipyretic, 
tonic, antiperiodic, antiseptic, emmenagogue and ecbolic. 
Uses. — Valuable stimulant in a slow first stage. It is com- 
bined with castor oil to bring on labor at term. Castor oil 1 
oz. and quinine sulphate 10 gr. is given as the first dose, fol- 
lowed in an hour by another 10 gr. of quinine, and an hour 
later by another. 
Dose.— 2-20 gr. 



THERAPEUTIC INDEX 



34,9 



Regulin. A mixture of agar-agar in dry form with extract of 
cascara sagrada. 

Uses. — A laxative in chronic constipation. 
Dose. — Teaspoonful to tablespoonful in stewed fruit or 
mashed potatoes, once daily. 
Russian Oil (Liquid Petrolatum). Laxative in pregnancy and 
puerperium. Acts mechanically and as a lubricant. Not 
unpleasant to take. 

Dose. — y 2 oz. at bedtime, and, if necessary, before each meal. 
May be given to breast-fed babies in doses of gtts. xv three 
times daily. 

Senna. Laxative and purgative. Acts especially on the large 
intestine. Sometimes passes over in the milk to the child. 
Dose. — Fl. ext. 1-4 teaspoonfuls. In compound licorice pow- 
der the dose is 30-80 gr. (about 10 gr. of senna to the dose). 

Silver Nitrate. Caustic, antiseptic, stimulant, irritant and anti- 
gonorrhceic. Table salt neutralizes it. 

Uses. — 2% solution in water for pruritus vulva?. 1% solu- 
tion dropped into the eyes of the new-born to prevent oph- 
thalmia neonatorum. Do not neutralize the 1% solution. % 
gr. silver nitrate with 2 gr. of pepsin in capsule for pernici- 
. ous vomiting of pregnancy. 

Sodium Bicarbonate (Baking powder). Antacid, antirheumatic. 
Uses. — Gout, dyspepsia, acid stomach, acidosis, vomiting of 
pregnancy. Soothes the skin when burned. 

Sodium Chloride. (Salt.) 

For normal saline use 10 gr. to 3% oz. of water. For phys- 
iological salt solution, add 15 gr. of Sod. Carb. to every 31/2 
oz. of normal saline as made above. 

Sodium Citrate. A white odorless, granular powder with cool- 
ing salty taste. 

Uses. — Diuretic, antipyretic and refrigerant. Retards the 
coagulation of albumin in milk and aids the digestibility 
of proteins. May be indicated in gout and cystitis. 
Dose. — Internally, 15 to 60 gr. In the modification of cow's 
milk about two grains should be used for each ounce of the 
mixture. 

Spirits of Nitre, Sweet (Spirit Nitrous Ether). 4% solution of 
nitrous ether in alcohol. Diaphoretic, diuretic, antipyretic, 
stimulant, antispasmodic. 

Uses. — Fever, dropsy, vomiting of pregnancy, colic, anuria. 
Dose. — For adult, 20-60 gtts. For infants small doses often 
repeated. 

Stramonium (Jimson Weed). Hypnotic, narcotic, antispasmodic. 
Uses. — For haemorrhoids take TJng. Stramonii and Ung. Galli 
in equal amounts and apply. 



350 OBSTETRICS FOR NURSES 

Urotropin. A white powder soluble in water. Urinary antiseptic, 
diuretic. 

Uses. — Cystitis, typhoid bacilli in urine, gout. It makes the 
urine irritatingly acid when given long. It does not act 
in alkaline media. 
Dose. — 7%-10 gr. well diluted. 
Valerian. Anodyne, stimulant, antispasmodic and nervine. 
Uses. — Hysteria, hypochondriasis, headache. 
Dose. — 30-60 TTL of the fl. ext. by mouth, or by rectum 2 oz. 
of the following mixture may be used P.E.N, for hysteria: 

Pot. Brom. 1 oz. 

Ext. Valerian fl. dr. vi. 

Normal saline q.s. oz xii. 
Veratrum Viride (Hellebore). Sedative, emetic, diaphoretic, 
diuretic. Betards the heart's action without weakening it. 
Uses. — Eclampsia. 

Dose. — 1 to 4 1 of the fl. ext. is given hourly until the 
pulse comes down to 80. 
Veronal. Safe, reliable hypnotic. 

Uses. — Insomnia from hysteria, neurasthenia, and mental 
disturbance. 

Dose. — 5 to 15 gr. dissolved in hot tea, milk, or water. May 
repeat. 

Zinc. Tonic, astringent, antispasmodic. 

Uses. — Stearate of zinc is a valuable dressing in excoriations 
of buttocks and external genitals. 

Zinc Ointment. It is indicated for bedsores (decubitus) eczema, 
herpes, and intertrigo. Zinc ointment contains one part of 
zinc oxide to four parts of benzoinated lard. 

Ziratol. A mixture of phenols in soap, water, and glycerine. 
Antiseptic, deodorant and germicide. Eelatively odorless, 
easily soluble and does not injure hands, instruments, or 
rubber. It is said to be only 1/7 as toxic as carbolic acid. 
Used in solutiens of 0.5% up to 5%. 



GLOSSARY 



[Adapted from Doiland and Standard Dictionaries] 



Ab-nor'mal. Not normal; con- 
trary to the usual structure 
or condition. 

A-bor'tion. 1. The expulsion of 
the foetus before it is viable. 
2. Premature stoppage of a 
morbid or a natural process. 

Ab-ra'sion. 1. A rubbing or 
scraping off. 2. A spot rub- 
bed bare of skin or mucous 
membrane. 

Ab'scess. A localized collection 
of pus in a cavity formed 
by the disintegration of tis- 
sues. 

Ac-couch'e-ment. Delivery in 
childbed; confinement. 

Ac'e-tone. 1. A colorless liquid 
found in pyro-acetic acid and 
in naphtha. 2. Any member 
of the series to which the nor- 
mal or typical acetone be- 
longs. 

A'ci-do"sis. Acid intoxication 
of the system from the elab- 
oration or too much acid 
by faulty metabolism or the 
imperfect disposition of nor- 
mal amounts of acid. 

A-ci'nus, pi. acini. One (acini, 
more than one) of the small- 
est lobules of a compound 
gland. 

Al'bo-lene. An oily white sub- 
stance derived from petro- 
leum. 

Al'bu-mi-nu"ri-a. The presence 
of albumin in the urine. 

Al'ka-line. Having the reaction 
of an alkali. 



A'men-or-rhce"a. Absence or 
abnormal stoppage of the 
menses. 

Am-mo'ni-a. A colorless alka- 
line gas, NH 3 , of penetrating 
odor, and soluble in water, 
forming ammonia-water. Am- 
moniacal urine contains am- 
monia, which is one form of 
nitrogen excretion. 

An-ae'mi-a. A condition in 
which the blood is deficient in 
quantity or in quality. 

An'aes-the"si-a. Loss of feel- 
ing or sensation, especially 
loss of tactile sensibility, 
though the term is used for 
loss of any of the other senses. 

An'aes-thef'ic. 1. Without the 
sense of touch or of pain. 2. 
A drug that produces anaes- 
thesia. 

An'al-ge"si-a. Absence of sen- 
sibility to pain. 

An-aph'ro-dis"i-ac. A drug that 
allays sexual desire. 

An'a-sar"ca. An accumulation 
of serum in the cellular tis- 
sues of the body. 

An'en-ceph"al-ous. Having no 
brain. 

An'ky-lo"sis. Abnormal rigid- 
ity or stiffness of a joint. 

An'o-dyne. A medicine that re- 
lieves pain. 

An'te par'turn. Latin for "be- 
fore delivery. ' ' 

An-te'ri-or. Situated in front 
of, or in the forward part of. 



351 



352 



OBSTETRICS FOR NURSES 



An'ti-pe'ri-od"ic. A drug that 
tends to prevent recurrent at- 
tacks of disease. 

An'ti-sep"tic. 1. Preventing de- 
cay or putrefaction. 2. A 
substance destructive to poi- 
sonous germs. 

A-pe'ri-ent. Mildly cathartic. 

Ap-nce'a. The absence of res- 
piration — especially that form 
which occurs in a child de- 
livered by the Caesarean oper- 
ation. 

A-re'o-la. The darkish ring 
around the nipple. 

As-ci'tes. Dropsy (an accumu- 
lation of fluid) in the ab- 
domen. 

A-sep'sis. Absence of septic 
matter, or freedom from in- 
fection. 

As-phyx'i-a. Suffocation. 

As-trin'gent. 1. Causing con- 
traction and arresting dis- 
charges. 2. An agent that 
arrests discharges. 

At'e-lec-ta"sis. Imperfect ex- 
pansion of the lungs at birth; 
partial collapse of the lung. 

At'on-y. Lack of normal tone 
or strength. 

A'tri-um. L., a hall.) The 
point of entrance of a bac- 
terial disease. 

At'ti-tude. A posture or posi- 
tion of the body. The rela- 
tion which the various ])arts 
of the child's body bears to 
its own long axis. The atti- 
tude of the foetus normally is 
complete flexion. 

Aus'cul-ta"tion. The act of lis- 
tening for sounds within the 
body. 

Bac-te'ri-a. The vegetable mi- 
croorganisms (Schizomycetes) 
especially the short-rod forms. 

Bal'an-i"tis. Inflammation of 
the glans penis. It is usual- 
ly associated with phimosis. 



Bal-lotte'nient. The diagnosis 
of pregnancy by pushing up 
the uterus by a finger in- 
serted into the vagina so as 
to cause the embryo to rise 
and fall again like a heavy 
body in water. 

Bar'tho-lin glands. The vulvo- 
vaginal glands. 

Bleb. A skin vesicle filled with 
fluid. A blister. 

Breg'ma. The point on the sur- 
face of the skull at the junc- 
tion of the coronal and sagit- 
tal sutures. 

Cas-sa're-an sec'tion. (Named 
from Julius Caesar, who is 
said to have been thus born). 
Delivery of the foetus bv an 
incision through the abdom- 
inal and uterine walls. 

Ca'put. Any head, or head-like 
structure. 

Ca'put suc'ce-da"ne-um. A 
swelling formed on the pre- 
senting part of the foetus 
during labor. It is due to 
the effusion of fluid into the 
subcutaneous tissues, of the 
scalp and its retention there. 

Car-min'a-tive. Drugs that 
stimulate the circulation, the 
mental faculties, and intes- 
tinal peristalsis. Asafoetida, 
camphor, capsicum, cardamon. 
chloroform, ether, ginger, 
horseradish, mustard, and the 
oils of anise, cloves, spear- 
mint, nutmeg and valerian 
are carminatives. 

Car'ne-ous. Fleshy. 

Cath'e-ter, tra'che-al. A long 
slender tube designed for in- 
troduction into the babe's 
trachea as a means of suck- 
ing out mucus. 

Cath"e-ter-ize'. To introduce a 
tube and draw off fluid, as 
urine or mucus. 



GLOSSARY 



Caul. 1. The great omentum. 

2. A piece of amnion which 

sometimes envelopes a child's 

head at birth. 
Cell. 1. Any one of the minute 

protoplasmic masses which 

make up organized tissue. 
Ceph-al'ic. 1. Pertaining- to the 

head. 2. A medicine for the 

head. 

Ceph'al-hae-ma-to"ma. 1. A tu- 
mor or swelling filled with 
blood beneath the pericrani- 
um. 

Cer'vix. The neck or any neck- 
like part. 

Chlo-as'ma. The yellowish brown 
spots or patches that appear 
on the shin of pregnant wom- 
en. 

Cic'a-tri"cial. Pertaining to, 
or of the nature of, a cicatrix. 

Ci-ca'trix. A scar; the mark 
left by a sore or wound. 

Cil'i-a. 1. The eyelashes. 2. 
Minute lash-like processes 
that characterize certain cells. 

Cli'mac-ter"ic. A particular 
epoch of the ordinary term of 
life at which the body is be- 
lieved to undergo a radical 
change — especially applied to 
the menopause. 

Cli-ni'cians. Men who teach 
and explain diseases by show- 
ing actual cases. 

Clit'o-ris. The sensitive organ 
of the female, homologous 
with the penis in the male. 

Coc'cyx. The small bone situ- 
ated at the end of the sacrum. 
The very last portion of the 
spine. 

Col-lapse'. A state of extreme 
prostration and depression 
with failure of circulation. 

Col'les' mem'brane. A layer of 
tough sensitive fascia bach 
of the perineum and on either 
side of the vagina. 



Co-los'trum. The first fluid se- 
creted by the mammary 
glands after functional ac- 
tivity begins. It contains 
casein ami more albumen than 
milk, as well as numerous 
fatty globules. 

Col'peu-ryn"ter. A dilatable 
bag, used to distend the 
vagina. 

Co'ma. Profound stupor occur- 
ring in the course of a dis- 
ease or after severe injury. 

Co'ma-tose. Pertaining to, or 
affected with, coma. 

Com'pli-ca"tion. A disease or 
diseases concurrent with an- 
other disease. 

Con-cep'tion. The fecundation 
of the ovum. 

Con'dyl-o"ma. A wart-like ex- 
crescence near the anus or 
vulva. It may be as large as 
a cauliflower. 

Con-gen'i-tal. Born with a per- 
son; existing at or before, 
birth. 

Con'ju-gate. The anteroposte- 
rior diameter of the pelvic 
inlet. 

Cor'o-nal. Pertaining to the 
crown of the head, as the 
coronal suture. 

Cra'dle cap. The dirty looking 
patch of epithelial scales and 
sebaceous material that de- 
velops over the anterior fon- 
tanellc of babies who have 
the exudative diathesis. 

Cra'ni-ot"o-my. The cutting in 
nieces of the foetal head to 
facilitate delivery. 

Cre-de Expression. The maneu- 
ver in which the uterus is 
grasped in the hollow of the 
hand and squeezed and 
pressed down upon to aid in 
the expulsion of the placenta. 



354 



OBSTETRICS FOB NURSES 



Cre-de Treatment. The instil- 
lation of a 1% solution of 
nitrate of silver into the eyes 
of the new-born to prevent 
ophthalmia. 

Curd. The coagulum of milk, 
consisting mainly of casein. 

Cy'an-o"sis. Blueness of the 
skin, often due to cardiac 
malformation causing insuf- 
ficient oxygenation of the 
blood. 

Cys-ti'tis. Inflammation of the 
bladder. 

De-cid'u-a. The membranous 
structure produced in the 
uterus during gestation and 
thrown off after parturition. 
D. reflexa, the part of decidua 
which is reflected upon and 
surrounds the ovum. D. sero- 
tina, the late decidua; the 
part of the decidua vera 
which becomes the maternal 
portion of the placenta. D. 
Vera, the true decidua; the 
portion of the decidua which 
lines the uterus. 

De-cu'bi-tus. 1. An act of ly- 
ing down. 2. A bed-sore. 

De-hy'drate. To remove the 
water. 

Di'a-be"tes. A disease marked 
by an habitual discharge of 
an excessive quantity of urine 
and the presence of sugar 
therein. 

Di"aph-o-re'sis. Perspiration, 
and especially profuse per- 
spiration. 

Di"aph-o-ret'ic. 1. Stimulating 
the secretion of sweat. 2. A 
medicine that increases the 
perspiration. 

Di-ath'e-sis. Natural or eon- 
genital predisposition to a 
special disease. 

Dif'fer-en"tial. Pertaining to a 
difference, or differences. 



DiS-crete'. Separate lesions 
which do not blend or 
coalesce. 

Di'u-re"sis. Increased secretion 
of urine. 

Dor'sum. The back or any part 
corresponding to the hack as 
the dorsum of the penis or 
foot. 

Duc'tus ve-no'sus. A foetal 
blood vessel connecting the 
umbilical vein with the post- 
cava. 

Dys-cra'si-a. A depraved state 
of the system, and especially 
of the blood, due to constitu- 
tional disease. 

Dysp-nce'a. Difficult or labored 
breathing. 

Dys-to'ci-a. Painful or slow 
delivery or birth. 

Ec-bOl'ic. An agent that accel- 
erates labor. 

E-clamp'si-a. A sudden attack 
of convulsions, especially one 
of a peripheral origin. 

Ec-top'ic. Out of the normal 
place. 

E-de'ma. Swelling due to ef- 
fusion of watery liquid into 
the connective tissue. 

Em'bo-lism. The plugging of 
an artery or vein by a clot 
or obstruction which has been 
brought to its place by the 
blood-current. 

Em'bry-o. The foetus in its 
earlier stages of development, 
especially before the end of 
the third month. 

Em-men'a-gogue. A drug that 
aids or stimulates menstrua- 
tion. 

E-mul'sion. An oily or resinous 
substance divided and held 
in suspension through the 
an-encv of an adhesive, muci- 
la vinous, or other substance. 

En'do-me"tri-um. The mucous 
membrane that lines the cav- 
ity of the uterus. 



GLOSSARY 



355 



En-gage'ment. The head is said 
to bo engaged when the larg- 
est diameters have passed the 
inlet. 

En'si-form. Shaped like a 
sword. 

Ep'i-si-ot"o-my. Surgical inci- 
sion of tlie vulvar orifice lat- 
erally for obstetric purposes. 

E-ro'sion. An eating or gnaw- 
ing away. 

Er'y-the"ma. A morbid redness 
of the skin due to congestion 
of the capillaries, of many 
varieties. 

E'ti-ol"o-gy. The study or 
theory of the causation of any 
disease. 

Ex-co"ri-a'tion. Any superficial 
loss of substance such as that 
produced on the skin by 
scratching. 

Ex'os-mo"sis (E.r-ox-mo.sc). Dif- 
fusion or osmosis from within 
outward. 

Ex-san'guin-a"tion. An exhaus- 
tion of the blood from a part 
or the whole of the body. 

Ex-trac'tion. The process or act 
of pulling or drawing out, 
particularly the removal of a 
child by pulling either with 
hands or forceps. 

Ex'tra-u"ter-ine. Situated or 
occurring outside of the 
uterus. 

Ex"u-da'tive di-ath'e-sls. A con- 
genital predisposition to ec- 
zema in various parts of the 
body, as well as to infections 
of the respiratory tract. 

Fae'ces (or fe'ees). The excre- 
ment or undigested residue 
of the food discharged from 
the bowels. 

Een'es-tra-ted. (L., fenestrum, 
a window.) Pierced with one 
or more openings, like win- 
dows. 



Fer'ment. Any substance that 
causes fermentation in other 
substances with which it 
comes in contact. 

Fi'brin. A substance which, 
becoming solid in shed blood, 
plasma and lymph, causes 
the coagulation of these fluids. 

Fil'let. 1. A loop-shaped struc- 
ture. 2. A loop, as of cord or 
tape, for making traction. 

Fis'sure. A cleft or groove, 
normal or other. 

Fis'tU-la. A dee] i, sinuous ul- 
cer, often leading to an in- 
ternal hollow organ. 

Flu'id ex'tract. A concentrated 
solution of the active prin- 
ciple of a drug in such 
strength that 1 c.c. of the 
product equals 1 gr. of the 
crude drug. The fluid is a 
mixture of alcohol, water and 
glycerine in varying propor- 
tions. One may be omitted. 

Foe'tus (or fe'tus). The unborn 
offspring of any animal that 
brings forth living progeny; 
the child in the womb after 
the third month. 

Fon'ta-nelle". Any one of the 
unossifiod spots on the crani- 
um of a young infant. It is 
so named because it rises and 
falls like a fountain. 

Fo-ra'men. A hole or perfora- 
tion, especially a hole in a 
bone. 

Four-chette'. The fold of mu- 
cous membrane at the poste- 
rior junction of the labia ma- 
jora. 

Fraj'num (or fre'num). A fold 
of the integument or of the 
mucous membrane that cheeks, 
curbs, or limits the move- 
ments of an organ in part — 
as the frsenum of the tongue. 

Func'tion. The normal or 
proper action of an organ or 
set of organs. 



356 



OBSTETRICS FOB NURSES 



Func'tion-al. Of or pertaining 
to a function. 

Fun'dns. The base or part of 
a hollow organ remotest from 
its mouth. 

Ga-lac'tor-rhce"a. Excessive se- 
cretion of milk. 

Ga-vage'. Feeding by the stom- 
ach tube; also the thera- 
peutic use of a very full diet. 

Gen'it-als. The reproductive or- 
gans. 

Ger"mi-cide'. An agent that de- 
stroys germs. 

Ges-ta'tion. Pregnancy. 

Glans cli-tor'i-dis. The distal 
or outside end of the clitoris. 

Glans pe'nis. The head, or 
terminal end, of the penis. 

Gon-or-rhce'a. A contagious 
catarrhal inflammation of the 
genital mucous membrane. 

Graaf'i-an fol'li-cle. Any one 
of the small spherical ovarian 
bodies, each of which con- 
tains an ovum. 

Haem'o-pliil"i-a. A condition of 
the system wherein bleeding 
occurs readily, and the blood 
clots slowly or not at all. 

Haem'or-rhage. A copious es- 
cape of blood from the ves- 
sels; bleeding. Accidental h., 
haemorrhage during pregnancy, 
due to premature detachment 
of the placenta. Post partum 
h., that which occurs soon af- 
ter labor, or childbirth. 
Unavoidable h., that which re- 
sults from the detachment of 
a placenta pra)via. 

Haem'or-rhoid. A pile, or vascu- 
lar tumor of the rectal mu- 
cous membrane. 

Hy-dat'id. An encysted vesicle 
containing an encysted fluid. 
From the Grcclc "Hydatis," 
meaning a drop of water. 



Hy-dat'i-form. Resembling a 

hydatid in form. 
Hy-dram'ni-os. Dropsy of the 

amnion. 

Hy'dro-ceph"a-lous. A fluid ef- 
fusion within the cranium. 
This disease is marked by 
enlargement of the head, with 
prominence of the forehead, 
atrophy of the brain, mental 
weakness, and convulsions. 

Hy'giene. The science of health 
and of its preservation. 

Hy'men. The membranous fold 
which partially or wholly oc- 
cludes the external orifice of 
the vagina, at least during 
virginity. 

Hy'per-em"e-sis. Excessive vom- 
iting. H. gra-vi-da'rum, ex- 
cessive vomiting of preg- 
nancy. 

Hy'per-ae"mi-a. Excess of blood 
in any part of the body. 

Hy-per'tro-phy. The morbid en- 
largement or overgrowth of a 
part. 

Hyp-not'ic. A drug that in- 
duces sleep. 

Hy'po-der-moc"ly-sis. The in- 
troduction, into (the subcu- 
taneous tissues, of fluid in 
large quantity. 

Hy'po-gas"tric. Of or pertain- 
ing to the lower anterior re- 
gion of the abdomen in the 
middle line of the body. The 
hypogastric arteries arise 
from the internal iliac in ad- 
dition to the branches given 
off from those vessels in the 
adult. 

Hy'po-phos"phite. Any salt of 
hypophosphorous acid. 

Ic'ter-us. Jaundice. 

Id'i-o-syn"cra-sy. An effect ab- 
normal to the one usually 
produced. An effect peculiar 
td the individual. 



GLOSSARY 



357 



Im-mu'ni-ty. The condition of 
being immune or exempt from 
disease, especially the condi- 
tion arising from inoculation, 
or from a peculiar resistance 
of the organism. 

Im'preg-na"tion. 1. The act of 
fecundation or of rendering 
pregnant. 2. The process or 
act of saturation, a saturated 
condition. 

In'farct. A mass of substance 
extravasated either into the 
substance of an organ or into 
a vessel due to the obstruc- 
tion to the circulation. 

In"fan-tile' pel'vis. A pelvis 
which has not responded to 
the developmental stimulation 
of the sexual glands at 
puberty, and therefore re- 
mains in its infantile shape. 
A masculine pelvis. 

In"fan-tile' u'ter-us. An unde- 
veloped uterus. 

In-fec'tion. The cummunica- 
tion of disease from one per- 
son to another, whether by 
effluvia or by contact, medi- 
ate or immediate; also the im- 
plantation of disease from 
without. 

In'nl-tra"tion. To cause a liquid 
or gas to penetrate or enter 
by pores or interstices. 

In'fiam-nia"tion. A morbid con- 
tion characterized by pain, 
heat, redness and swelling. 

In-nom'in-ate. Not having a 
name, as the innominate bone. 

In-som'ni-a. Inability to sleep; 
abnormal wakefulness. 

In'ter-sti'tial. Pertaining to, or 
situated in, the interstices or 
interspaces of a tissue. 

In'ter-tri"go. A chafe, or 
chafed patch of the skin; also 
the erythema or ec/.ema that 
may result from a chafe of 
the skin. 



In-tro'i-tus. The entrance to 
any cavity or space. 

In-ver'sion. A turning inward, 
inside out, upside down, or 
other reversal of the normal 
relation of a part. 

In'vo-lu"tion. 1. A rolling or 
turning inward. 2. The re- 
turn of the uterus to its nor- 
mal size after parturition. 
A retrograde change, the re- 
verse of evolution. 

Is-chu'ri-a par-a-dox'a. A con- 
dition in which the bladder is 
over-distended with urine, al- 
though the patient continues 
to urinate, generally in drib- 
bles. 

Jaun'dice. Yellowness of the 
skin, eyes, and secretions, due 
to the presence of bile pig- 
ments in the blood. 

La'bi-a. Lip-shaped organs. 
The external folds of the 
vulva, labia majora, and the 
internal folds of the vulva, 
labia minora. 

Lac'e-ra"tion. .1. The act of 
tearing. 2. A wound made 
by tearing. 

Lac-ta'tion. 1. The secretion of 
milk. 2. The period of the 
secretion of milk. ?>. Suckling. 

Lan-U'go. The fine hair on the 
body of the fetus. 

Lav-age'. The irrigation or 
washing out of an organ, such 
as the stomach or bowel. 

Le'sion. Any hurt, wound or 
local degeneration. 

Leu'cor-rhce"a. A whitish, vis- 
cid discharge from the vagina 
and uterine cavity. 

Light'en-ing. The sense of 
lightness and easier breath- 
ing that follows the descent 
of the head into the pelvis 
during the last three weeks 
of pregnancy. It is most 
likely to occur in primip- 
aras. 



OBSTETRICS FOR NURSES 



Lo'chi-a. The vaginal discharge 
that takes plaee during the 
first week or t wo after child- 
birth. 

Lymph. A transparent slightly 
yellow liquid of alkaline re- 
action which fills the lym- 
phatic vessels. 

Mal-aise'. An uneasiness or in- 
disposition, discomfort or dis- 
tress. 

Mal'po-si"tion. Abnormal or 

anomalous position. 
Mani'ma. The mammary gland; 

the breast. 
Mam'ma-ry. Pertaining to the 

Mamma. 

Ma-ras'mus. Progressive wast- 
ing and emaciation, especial- 
ly such a wasting in young 
children when there is no 
obvious or ascertainable 
cause. 

Mas-sage'. The systematic, 
therapeutic friction, strok- 
ing and kneading of the body. 

Mas-ti'tis. Inflammation of the 
breast. 

Me-a'tus. A passage or open- 
ing, as the meatus urinarius. 
Me-lae'na ne-o-na-to'rum. The 

passage of dark pitchy stools 
containing blood pigments 
and blood that has been cx- 
travasated into the alimen- 
tary canal of the newborn 
babe. 

Mem'brane. A thin layer of 
tissue which covers a surface 
or divides a space or organ. 

Men'o-pause. The period when 
menstruation normally ceases: 
the change of life. 

Mis-car'riage. Abortion; pre- 
mature expulsion of the 
ftt'tus; birth of the foetus be- 
fore the twenty-eighth week. 



Milk-leg (Phlegmasia Alba Do- 
lens). A condition developing 

ing in one, and rarely, in both, 
legs, after delivery. It is due 
to occlusion of the veins of 
the pelvis and leg by throm- 
bosis or to septic inflamma- 
tion of the pelvic connective 
tissue. 

Mole. 1. A fleshy mass or tu- 
mor formed in the uterus by 
the degeneration or abortive 
development of an ovum. 2. 
A nevus; also a brownish spot 
on the skin. 

Mons ven'er-is. A rounded 
prominence at the symphysis 
pubis of a woman. 

Mor-bid'i-ty. The condition of 
being diseased or morbid. 

Mor'cel-la"tion. Division am! 
piecemeal removal. 

MU'CUS. The viscid watery se- 
cretion of the mucous glands. 

Mul-tip'ar-a. A woman who 
has borne more than one 
child. 

Mum'mi-fi-ca"tion. Dry gan- 
grene; also the drying up and 
shrivelling of the foetus. 

Myd'ri-at"ic. A drug that di- 
lates the pupil. 

Nau'se-a. Tendency to vomit; 
sickness at the stomach. 

Ne-cro'sis. Death of a tissue. 

especially of a hone. 
Ne-phri'tis. Inflammation of 

the kidney. 
Neu-rot'ic. 1. Pertaining to or 

affected with a neurosis. l!. 

Pertaining to the nerves. 
Neu'tra-lize. To lender neutral 

or ineffective. 
Ni'tro-gen. A colorless gaseous 

element found free in air. 
Nod'u-lar. 1. Pike a nodule or 

node. 2. Marked with nod- 
ules. 



GLOSSARY 



:;.")!) 



Nu'tie-us. 1. a spheroid body 
within a cell, forming the es- 
sential and vital part. 2. .V 
mass of gray matter in the 
central nervous system. 3. 
In chemistry, the central ele- 
ment in the molecule of a 
eompouD d. 

Nu'tri-ent. Nourishing; afford- 
ing nutriment. 

Nym'phae. The labia minora. 

Ob-stet'rics. The art of man- 
aging childbirth cases; that 
branch of surgery which deals 
with the management of preg- 
nancy and labor. 

Ob-ste-tri'cian. One who prac- 
tices obstetrics. 

Oc'ci-put. The back part of the 
head. 

Ol'i-go-hy-dram"ni-os. Scanti- 
ness of the liquor amnii. 

01'i-gop-nce"a. A delay follow- 
ing the birth of a child be- 
fore the first respiration is 
established. 

Oph-thal'mi-a. Severe inflam- 
mation of the eye or of the 
conjunctiva. 

Or'gan. Any part of the body 
having a special function. 

Os. ( L., a mouth.) The orifice 
in the uterus or vagina. 

Os-mo'sis. The passage of a 
fluid through a membrane. 

O'va. Latin plural of ovum. 

oo' 

0'vu-la"tion. The formation and 
discharge of an unimpreg- 
nated ovum from the ovary. 

O'vule. 1. The ovum within 
the Graafian vesicle. 2. Any 
small egg-like structure. 

O'vum. 1. An egg. 2. The 
female reproductive cell 
which, after fertilization, de- 
velops into a new member of 
the same species. 

Ox'y-di"zer. Anything that 
combines with oxygen. 



Pal-pa'tion. The act of feeling 
with the hand; the applica- 
tion of the lingers with light 

pressure to the surface of the 
body for the purpose of de- 
termining the consistence of 
the parts beneath in physical 
diagnosis. 

Par-a"/y-sis, Erb's. 1. Same as 
birth-palsy. 2. Partial paral- 
ysis of the brachial plexus af- 
fecting various muscles of the 
arm and chest-walls. It is 
revealed by an inability to 
lift the arm toward the head. 

Par-al'y-sis facial (Bell's). 
Paralysis of the face, due to 
lesion of the facial nerve or 
of its nucleus. 

Par'a-me-tri"tis. Inflammation 
of the parametrium, or cellu- 
lar tissue about the uterus. 

Par'a-phi-mo"sis. Retraction of 
a narrow or inflamed fore- 
skin which can not be re- 
placed. 

Pa-ren'chy-ma. The essential 
or functional (dements of an 
organ as distinguished from 
its stroma or framework. 

Pa-ri'e-tal. Of, or pertaining 
to, the walls of a cavity. 

Par'o-nych"i-a. Infection and 
suppuration about the junc- 
tion of nails and skin. 

Par'ox-ysm. A sudden recur- 
rence or sudden intensifica- 
tion of symptoms. 

Path-o-log'ic. Pertaining to 
pathology. 

Pa-thol'o-gy. That branch of 
medicine which treats of the 
essential nature of disease, 
especially of the structural 
and functional changes caused 
by disease. 

Pel-vim'e-ter. An instrument 
for measuring the various di- 
ameters of the pelvis. 



OBSTETRICS FOR NURSES 



Pel-vini'e-try. The act of deter- 
mining the dimensions of the 
pelvis by moans of a pelvim- 
eter. 

Per'i-ne-or"rha-phy. Suturation 
of the perineum, performed 
for the repair of a laceration. 

Per'i-ne"um. The space or area 
between the anus and the 
genital opening. 

Pe-riph'e-ry. The outward part 
or surface. 

Per'i-to-ne"um. The serous 
membrane which lines the ab- 
dominal walls. 

Per'i-to-ni"tis. Inflammation of 
the peritoneum. 

Per'i-stal"sis. A worm-like 
movement by which the ali- 
mentary canal propels its 
contents. 

Per-ni'cious. Tending to a fatal 
issue. 

Phe-nom'e-non. Any remark- 
able appearance; any sign or 
objective symptom. 

Phys'i-o-log"ic. Pertaining to 
physiology. 

Phys'i-ol"o-gy. The science 
which treats of the functions 
of the living organism and 
its parts. 

Phi-mo'sis. Tightness of the 
foreskin such that, it can not 
be drawn back over the glans. 

Phle-bi'tis. Inflammation of a 
vein. 

Pig'men-ta"tion. The deposition 
of coloring matter. 

Pla-cen'ta prae'vi-a. A placenta 
which intervenes between the 
intra-uterine cavity and the 
inner orifice of the cervical 
en nal. 

Pla-cen'ta suc'cen-tur'i-a"ta. An 

accessory or subsidiary pla- 
centa. 

Pled'get. A small compress or 
tuft as of wool or lint. 



Pleth'o-ra. A condition marked 
by vascular turgescencc, ex- 
cess of blood and fullness of 
pulse. 

Po-dal'ic. Pertaining to, or ac- 
complished by means of, the 
feet. 

Pol'y-hy-dram"ni-os. Excess in 
the amount of the liquor 
amnii in pregnancy. 

Po-si'tion. 1. The attitude or 
posture of a patient. 2. The 
relation of the presenting part 
of the foetus to the quadrants 
of the maternal pelvis. 

Pos-te'ri-or. Situated behind 
or toward the rear. 

Post par'tum. After delivery. 

Pre'ma-ture. 1. Occurring lie- 
fore the proper time. 2. An 
infant born before its proper 
term, but viable. 

Pre'ma-tu"ri-ty. The condition 
of a child that has been de- 
livered before term, and be- 
fore maturity or ripening has 
taken place. 

Pre-mon'i-tory. Serving as a 
warning. 

Pre'puce. The fold of shin 
covering the glans penis; the 
foreskin. 

Pres'en-ta"tion. 1. The appear- 
ance in labor of some particu- 
lar part of the feetal body at 
the os uteri. 2. That part of 
the foetal body which fust 
shows itself at the os in labor. 

Pri-mip'a-ra. A woman who 
has given birth, or who is giv- 
ing birth, to her first child. 

Prod'ro-mal. Premonitory. In- 
dicating the approach of an 
event, phenomenon, or dis- 
ease. 

Prog-no'sis. A forecast, as to 
the probable result of an at- 
tack of disease; the prospect 
as to recovery from a disease 
afforded by the nature and 
symptoms of the case. 



GLOSSARY 



361 



Pro-jec'tion-al vom'i-ting. Sud- 
den violent emeads, 

Pro-lapse'. The falling down, 
or sinking, of a part or vis- 
ens. 

Pro-lep'sis. The anticipation 
and nullification of complica- 
tions before they arise. 

Prom"on-to'ry. A projecting 
eminence or process. 

Pro'phy-lax"is. The prevention 
of disease. 

Pro'te-in. Any one of a group 
of nitrogenized, noncrystal- 
lizable compounds similar to 
each other, widely distrib- 
uted in the animal and vege- 
table kingdoms, and forming 
the characteristic constitu- 
ents of the tissues and fluids 
of the animal body. They .ire 
formed by plants, the an- 
imal organism receiving them 
as food and transforming and 
assimilating them. They all 
contain carbon, hydrogen, 
nitrogen, oxygen and sulphur. 
Some of the most important 
are albumin, casein. legumin, 
fibrin, myosin and glutin. 

Psy'chic. Pertaining to the 
mind. 

Pu'bes. That part of the low- 
er central hypogastric region 
which, in the adult, is cov- 
ered with haii-. The pubic 
region. 

Pu'bic. Pertaining to the 
pubes, or os pubis. 

Pu'ber-ty. The age at which 
the reproductive organs be- 
come functionally operative. 

Pu'bi-ot"o-my. ( Ue-bos'te-of o- 
iii it. i The operation of cutting 
through the pubic bone, lateral 
to the median line. 

Pu-er'pe-ral. Pertaining to 
childbirth. 



Pu'er-pe"ri-um. The period or 
stale of confinement. The 
puerporium is the time suc- 
ceeding labor which is neces- 
sary for the restoration of 
the genitals to their condi- 
tion previous to pregnancy, 
or as near it as possible. It 
varies from (! weeks to sev- 
eral months. 

Pu'ru-lent. Consisting of or 
containing pus. 

Py-as'mia. Blood-poison of mi- 
crobic origin. 

Py'e-li"tis. Inflammation of the 
pelvis of the kidney, 

Py'or-rhoe"a. A discharge of 
pus, especially from infection 
around the roots of the teeth. 

Py-ro'sis. Heartburn. Acidity 
of the stomach. Eructations 
of acid. 

Re'fiex-es. Reflected actions or 
movements. Impulses re- 
ceived and transmitted by the 
nervous system without con- 
scious volition. Involuntary 
responses to irritation. Auto- 
matic movements. 

Re-frig'e-rant. Relieving fever 
and thirst. A cooling remedy. 
Acidulous drinks and evapo- 
rating lotions are refrigerant. 

Re-gur'gi-ta"tion. 1. The cast 
ing up of undigested food. 2. 
A backward flowing of the 
blood th rough the left auri- 
culo-ventricular opening, on 
account of imperfect closure 
of the mitral value. 

Re'lax-a"tion. 1. A lessening of 
tension. 2. A mitigation of 
pain. 

Re'nal. Pertaining to the kid- 
ney. 

Res'ti-tu"tion. 1. An act or 

process of restoration. '2. 
The rotation of the present - 
ing part of the foetus outside 
of the vagina. 



362 



OBSTETRICS FOR NURSES 



Re'tro-gres"sive. Going- or 
moving backward. Passing 
from a better to a worse con- 
dition. 

Re'tro-ver"sion. The tipping of 
an entire organ backward. 

Rick'etS. (BarcM'tis.) A con- 
stitutional disease of childh 1 

in which tlic bones become soft 
and flexible from retarded os- 
sification, due to deficiency of 
the earthy salts. 

Ro-ta'tion. The process of turn- 
ing around an axis. 

Rough'en-ing. Any rough, 
coarse food that gives bulk to 
the intestinal contents with- 
out much nutrition. 

Ru'be-fa"ci-ent. An agent that 
reddens the skin. 

Ru'gae. Wrinkles or folds. 

Rup'ture. 1. Forcible tearing 
or breaking of a part. 2. 
Hernia. 

Sa'cnun. The triangular bone 
situated at the end of the 
spine. It is formed of live 
vertebrae, amalgamated and 
wedged in between the two 
innominate bones. 

Sag'it-tal. Shaped like, or re- 
sembling, an arrow. 

Sal'i-va"tion. An excessive dis- 
charge of saliva. 

Sal'pin-gi"tis. Inflammation of 
an oviduct or of the eustach- 
ian tube. 

Sal"var-san'. A compound in- 
vented by Ehrlich for the 
treatment of diseases caused 
by the Spirilla', such as 
syphilis and recurrent fever. 
It is popularly called 606. 

Sa-prae'mi-a. Poisoning of the 
blood by the absorption of 
toxins from localized infec- 
tions as from the uterus. 

Scap'u-la. The shoulder blade. 

Scro'tum. The pouch which 
contains the testicles and 
their accessory organs. 



Se-ba'ceous. 1. Pertaining to 
sebum or suet. 2. Secreting a 
greasy Lubricating substance 

Se-cre'tion. 1. The process or 
function of separating vari- 
ous subsl ances from t he blood. 
2. Any secreted substance. 

Sec'un-dines. All that remains 
in the uterus after the birth 
of the child is called sccun- 
dines — placenta, membrane 
and cord. 

Se'men. 1. A seed or seed-like 
fruit. 2. The thick whitish 
liquid fecundating secretion 
produced in coition. 

Shock. Sudden vital depres- 
sion, due to an injury or emo- 
tion which makes a sinister 
impression upon the nervous 
system. 

Show. The appearance of blood 
that foreruns a labor or men- 
struation. 

Sm'a-pism. A plaster or paste 
of ground mustard-seed; a 
mustard plaster. 

Sin'ci-put. The portion of the 
head lying in front of the an- 
terior or large fontanelle. 

Si'nus. 1. A recess, cavity or 
hollow space. 2. A dilated 
channel for venous blood, 
found chiefly within the cra- 
nium and uterus during gesta- 
tion. 3. An air-cavity, in one 
of the eranial bones, especial- 
ly one communicating with 
the nose, such are the eth- 
moidal frontal maxillary and 
sphenoidal sinuses. 4. A sup- 
purating channel or fistula. 

Smeg'ma. A thick, choosy, ill- 
smelling secretion found un- 
der the prepuce and around 
the labia minora. 

So-lu'tion. 1. The process of 
dissolving. 2. A liquid con- 
taining dissolved matter. 



GL( (SSARY 



363 



Sor'des. The dark brown mat- 
ter which collects on the lips 
and teeth in low fevers. 

Spas'mo-phil"ic di-ath'e-sis. Is 

a condition characterized by 
an increased elective irritabil- 
ity and a tendency to spasm, 
like contractions of one or 
more groups of muscles. 
(.Grulee). 
Spe-cif'ic. 1. Pertaining to a 
species. 2. Produced by a 
single kind of microorganism. 
3. A remedy specially indi- 
cated for any particular dis- 
ease. 

Sper'ma-to-zo"on. The motile 
generative element of the se- 
men which serves to impreg- 
nate the ovum. 

Spi'na bif'i-da. Congenital 
cleft of the vertebral column 
with meningeal protrusion. 

Spi'ro-chae"te. A genus or form 
of flexile spirobacteria. 

Sta'sis. A stoppage of the flow 
of fluid in any organ or any 
part of the body. 

Ste-no'sis. Narrowing or stric- 
ture of a duct or canal. 

Ster'ile. Nonfertile. 

Ster'il-i-za"tion. The act or 
process of rendering sterile. 

Still-birth. The birth of a dead 

f OctUS. 

Stim'u-lant. 1. Producing stim- 
ulation. 2. An agent or rem- 
edy that produces stimulation. 

Strep'to-coc"cus. A genus or 
form of bacterial organism, 
which grows in consecutive 
links, like a chain. 

Stri'a, pi. strice. Streaks or 
lin es. 

Stro'ma. The tissue which 
forms the ground substance, 
framework, or matrix of an 
o r^an. 

Styp'tic. Astringent, an agent 
for arresting haemorrhage. 



Sub'in-vo-lu"tion. Incomplete 
involution; failure of a part 
to return to its normal size 
and condition after enlarge- 
ment from functional activity. 

Sup-pos'i-to-ry. An easily fus- 
ible medicated mass to be in- 
troduced into the vagina, rec- 
tum, or urethra. 

Su'ture. 1. Surgical stitch or 
seam. 2. The line of junc- 
tion of adjacent cranial or 
facial bones. 

Sym'phys-e-ot"o-my. The divi- 
sion of the fibrocartilage of 
the symphysis pubis in order 
to facilitate delivery by in- 
creasing the anteroposterior 
diameter of the pelvis. 

Sym'phy-sis. The line of junc- 
tion and fusion between bones 
originally distinct. The sym- 
physis pubis. 

Syn'chro-nous. Occurring at the 
same time. 

Syph'i-lis. A contagious ven- 
eral disease leading to many 
structural and cutaneous le- 
sions, due to a microorganism 
called the spirochseta pallida. 

Tam'pon. A plug made of cot- 
ton, sponge, or oakum. 

Te-nac'u-lum. A hook-like in- 
strument for seizing and hold- 
ing tissues. 

Te-nes'mus. Straining, especi- 
ally ineffectual and painful 
straining. 

Throm'bus. A plug or clot in 
a vessel remaining at the 
point of its formation. 

Tinc'ture. The solution of me- 
dicinal substances in fluids 
other than water or glycer- 
ine. There is usually about 
one part of the drug to eight 
of alcohol. 

Tis'sue. An aggregation of 
cells, fibers and various cell- 
products forming a structural 
element. 



364 OBSTETRICS FOR NURSES 



Tox-ae'mi-a. Blood-poisoning. 
Tox'in. Any poisonous albumin 

produced by bacteria] action. 
Trau'ma. A blow, wound, or 

other violent injury. 
Trau'ma-tism. A condition of 

the system due to injury. 

Tu'mor. 1. Swelling; morbid 
enlargement. 2. A neoplasm. 
A mass of new tissue which 
persists and grows independ- 
ently ol' its surrounding struc- 
tures, and which has no physi- 
ologic use. 

Tym'pa-ni"tis. Distention of 
the abdomen from gas. 

Um-bil'i-cal. Pertaining to the 
umbilicus. 

Um-bi-li'cus. The navel. 

TJ'ra-chus. A cord that extends 
from the apex of the blad- 
der to the navel. It repre- 
sents the remains of the canal 
in the foetus which joins the 
bladder with the ailantois. 

U-re'a. A white erystallizable 
substance from the urine, 
blood and lymph. 

U-re'ter. The fibro-muscular 
tube which conveys the urine 
from the kidney to the blad 
der. 

TJ-rae'mi-a. The presence of 
urinary constituents in the 
blood and the toxic condition 
produced thereby. 

U-re'thra. A membranous canal 
conveying urine from the 
bladder to the surface and in 
the male conveying the sem- 
inal ejaculations. 

XJ'rin-al"y-sis. The chemical 
analysis of urine. 

U'ter-us. The hollow muscular 
organ which provides lodge- 
ment for the foetus from con- 
ception to birth. The womb. 



U'ter-us bi-cor'nis. A womb 
wherein the two sides have 

been Incompletely joined dur- 
ing development, and two 
horns, or protrusions, appear 
on the fundus. 
U'ter-us di-del'phys. A w b 

in which there has been sepa- 
rate development ami incom- 
plete fusion of the. tWO sides. 
U'ter-us du'plex. A double 
uterus. 

U'ter-us sep'tate. A uterus that 
is divided by a partition or 
septum. 

Var'i-cose veins. Of the nature 
of, or pertaining to, a varix. 
The permanent dilatation of 
a vein. 

Ven'e-sec"tion. The opening of 
a Vein for the purpose of let- 
tiny blood. 

Ven'tral stalk. An embryonic 
process which is the rudimen- 
tal precusor of the umbilical 
coiil. It is known as the ven- 
tral stalk because somewhat 
later in the course of develop- 
ment it becomes attached to 
the ventral (abdominal) sur- 
face of the embryo. 

Ver'nix cas'e-o"sa. A fattv sub- 
stance that covers the slvin of 
the foetus. 

Ver'sion. The act of turning, 
especially the manual turn- 
ing of the foetus in delivery. 
External v., that which is per- 
formed by outside manipula- 
tion. Internal v., version per- 
formed by the hand intro- 
duced into the uterus. Brax- 
ton Hicks' Version, a version 
done with the whole hand in 
the vagina and two fingers 
entering the uterus through 
the partially dilated os. 

Ves'i-cal. Pertaining to the 
bladder. 



GLOSSAB V 



365 



Vi'a-bil"i-ty. Able to live af- 
ter birth. 

Villi. I. The finger-like projec- 
tions that develop on the out- 
side of the eg» and connect it 
vascularly and otherwise with 
the uterus; a vascular chori- 
onic tuft. 2. A minute club- 
shaped projection from the 
mucous membrane of the 
intestine. 



Vul-sel'lum. A forceps with 
teeth on the ends of the jaws. 

Walch'er's position. The pa- 
tient on the back with the 
hips at the edge of the tabic 
and the legs hanging down. 

Whar'ton's jelly. The soft 
pulpy connective tissue that 
constitutes the largest part of 
the umbilical cord. 

Womb. Same as uterus. 



INDEX 



A 

Abderhaldeo tost for preg- 
nancy. 61 
Abdomen : 
care of, 70 

changes in pregnancy, 59 

weakness of, 85 
Abortion, 95 

etiology, 207 

management, 207 
Accessory articles of diet, 319 
Accidental haemorrhage, 228 
After-birth, 41, 117 
After pains, 154, 254 

relief of, 154 
Albuminuria, 77 (see Eclamp- 
sia) 

A cnenorrhoea, 57 

during lactation, 158 

in the nonpregnant, 58 
Amnion, 38 

adhesions, S7 
Anaesthetics, 103, 138, 142 
Anencephalus, 309 
Anus, 23 
Aphthae, 294 
Areola, 31 

Asepsis in delivery, 142 
Aseptic care, 200 
Asphyxia neonatorum, 278 

methods of resuscitation, 279 
Atelectasis, 283 
Attitude of child, 165 

B 

Baby: 

anencephalus, 309 
aphthae, 294 
asphyxia, 142, 278 
balanitis, 306 
bath, 266 
bowels, 273 
breasts, 293 
care after delivery, 144 

367 



Baby— Cont'd 

care at birth, 142 

circumcision. 306 

cleansing, 265 

clothing, 270 

colic, 299 

constipation, 29S 

convulsions, 282 

cradle cap, 295 

diarrhoea, 298 

exercise, 284 

eyes, 268 

furuncles, 305 

flushings, 285 

gavage, 285 

genitals, 272 

haemorrhage, 289 

harelip and cleft palate, 287 

heart, 278 

hernia, 287 

hydrocephalus, 308 

icterus, 293 

lavage, 286 

marasmus, 303 

menstruation, 293 

mouth, 272 

nails, 289 

nursing periods, 273, 156 
paraphimosis, 305 
phimosis, 305 
pneumonia, 304 
prematurity, 301 
priapism, 308 
respiration, first, 142 
routine for, 270 
significant symptoms and 

conditions, 320 
sleep, 272 
snuffles, 304 
spina bifida, 308 
temperature, 27<> 
thrush, 294 
tongue-tie, 28 i 
toilet basket. 271 



368 



INDEX 



Baby— Cont'd 

umbilicus, 207 

urticaria, 294 

vomiting, 300 

weight, 271 
Bag of waters, 39, 110 
Balanitis, 306 
Ballottement, 62 
Barley water, 316 
Baths', 69, 325 
Bed, making, 133 
Bed-linen, care of, 150 
Bed-sores, 263 
Bednar's disease, 294 
Bichloride solution, 135 
Birthmarks and deformities, 72, 
87 

Binder, 153 
Bladder, 23 

after delivery, 159 

in pregnancy, 5<>, 58 
Bleeders, 232, 290 
Blood, in pregnancy, 55 
Bowels, in pregnancy, 68 

in puerperium, 157 
Breast milk, quantity, |75 
Breasts, 30 

caked, 156, 243 

care of, 71 

changes due to marriage 
and pregnane y, 53, 59 

inflow of milk, 53 

massage, 156 

nursing periods, 156 

of puberty, 33 

preparation for lactation,!.").") 

removal of child, 252, 261 

sensations in pregnancy, 59 

supernumerary, 31 
Breech presentation, 168 
Brow presentation, 177, 179 
Buttermilk, 314 

C 

Caesarean section, 195 
Caput succedaneum, .127 
'"ase record, nurse's, 131 
< Jatheterization, 
after delivery, 159 
before operations, 183 



Caul. 114 

( 'ephalhsematoma, 1 28 
Cervix, effacement, 110 

repair, 144, 211 
Child (see Baby) 
Chill in puerperium, 151 
Chloasma, 55 
Chloroform in labor, 103 
Chorion, 38 
Circumcision, 306 
Clamp for cord, 268 
Clitoris, 20 
Coitus, 71 
Colic, 300 
Colostrum, .">•". 
Conception, 36 
Condylomata, 75 
Confinement, estimating date. 

58, 66 
Constipation, 68, 298 
Contraction of pelvis, 214 
Contractions of Braxton 

Hicks, 53, 62, 109 
Convulsions, of child, 282 

of mother, 236 
Cord, umbilical, 40 

attachment to placenta. 42 

cutting, 142 

granulations of, 29:1 

prolapse of, 220, 137 

separation, 292 
Cow's milk vs. breast milk 
311 

Cradle cap, 295 
Cramps, 56, 86 
Cranioclasis, 194 
Currettage of uterus. 206 

in abortion, 207 
Curve of Cams, 20 

D 

Decapitation, 194 

Delivery, asepsis during. 142 

care of mother after. 144 

on side, 140 
Diabetes and pregnancy. 95 
Diapers, 270, 273 

bluing on, 270, 296 



IXDI'.X 



369 



Diarrhoea of child, 298 
Diet in puerperium, 1 .1 l* , 155 
Diets, 336 
Doctor. 130 

when to call. 133 

what to report, 131, 319 
Douche, vaginal, 202 

aseptic, 200 

in pregnancy, 71, 160 

intrauterine, 205, 233 
Dress in pregnancy, 69 
Drugs affecting the milk, 275 
Dry birth. 22.", 
Ductus arteriosus, 49 

venosus, 48 

E 

Eclampsia, 7S 

blood pressure in, 55 
symptoms and management. 
237 

wet packs in, 231 
Ectopic pregnancy, 89 ' 
Edema, 69 

Enemas, eliminative, 355 

nutrient, 334 
Episiotomy, 23 1 
Ergot. 143 

after delivery, 150 

in abortion, 207 

in post partum haemorrhage, 

GOO 

Eruptions on the skin, 55 
Erythema, 296 
Ether in labor, 103 
Examination of patient. 134, 
140 

Excavation of pelvis, 19 
Extrauterine pregnancy. 89 
Exudative diathesis, 295 
Eye symptoms in pregnancy, 
69 

F 

Face presentation, 174, 179 
Fallopian tubes. 22 
Fainting, 70 

Fevers and pregnancy, 91 
Flour ball. 316 
Flushings, 285 



Ftetus, attitude, 44 
circulation, 48 
diameters of head. 4<i 
fontanelles, 46 
heart tones, 63, 180 
movements, 44, 62 
rate of growth, 46 
rule for estimating length, 
47 

rule for estimating Weight, 
47 

signs of danger to, 180 

signs of death. 97 
signs of maturity, 47 

Food mixings, 317 
preparation for infants, .''.14 

Foramen ovale, 50 

Forceps, application, 186 
conditions for, 185 
dangers of. 185 
in breech cases. 173 
in face presentations, 176 
indications for, 1 85 
preparations for, 183 

Fumigation, 329 

Furuncles, 305 

G 

Galactorrhea, 250 

Gas analgesia. 104 

Gas pains. 154. 158, 253 

(lavage, 285 

Genital crease, 25 

Genitalia, care after delivery, 

142, 14S 
preparation for delivery, 

131 

preparation for operation, 
182 

Getting up, 163 
Gingivitis, 75 
Glands, Bartholin. 27 

mammary, 30 

Montgomery, 33 

thyroid. 56 
Glossary, 351 
Glycosuria, 69 

Gonorrhoea and pregnancy, 93 
Goodell's sign, 60 
Gossip, 161 



370 



[NDEX 



Graafian follicle, 33 
Gums in pregnancy, 75 

H 

Haemorrhage, accidental, 228 

in abortion, 207 

in labor, 144, 119, 143 

in the newborn, 289 

in pregnancy, 95 

post partum, 232, 234 

unavoidable, 228 

uterine douche for, 205 
Hemorrhoids, 86 
Hair, 55, 132 
Hands, care of, 160, 323 

sterilization of, 134 
Earelip and cleft palate, 287 
Head, descent, 123 

expulsion of, 115 

effect of labor on, 126 

extension, 126 

external restitution, 126 

tlexion, 123 

internal rotation, 124 
Headache, 237, 254 
Heart changes in pregnancy, 
55 

lesions in pregnancy, 94 
Heart tones, fcetal, where 
heard, 130 
significance, 137 
when membranes rupture 
prematurely, 226 
Eegar 's sign, 60 
Hernia, 287 

Herpes in pregnancy, 76 
Hospital drums, packing, 138 
Hottentot apron, 26 
Hydramnios, 87 

and malpresentations, 175 

and twins, 84 
Hydrocephalus, 308 
Hymen, 26 
Hypodermoclysis, L'Oli 
Hyperemesis gravidarum, 79 

I 

Icterus, 293 

Induction of labor, 208 



Infant feeding, 310 

outfit, 101 
I nfect inn, 226, 255 
Injections, climinativc, 335 

intravenous, 205 

nutrient, 334 
Insomnia. -1(1 
Intertrigo, 296 
Involution, 152, 160, 161 

J 

Jacquemin's sign, 62 
Jaundice, of child, 293 
of mother, 95 

K 

K Ldneys of child, 44 
of mother, 56, 68, 95 

L 

Labia majora, 25 

minora, 26 
Labor, care during, 140 

induction of, 208 

precipitate, 223 

preparations for, 130, 138, 
326 

signs of, 129 

vomiting in, 228 
Lactation and menstruation, 

157 
Lavage, 286 
Leucorrhoea, 71 
Lightening, 65, 108 
Linea albicantes, 55 

nigra, 55 
Liquor amnii, 38 

in disease, 87 
Liver, of child, 44 

of mother in pregnancy, 56, 
95 

Lochia, 154 

and the hands, 160 
Longings, 56 
Lungs in pregnancy, 56 

M 

Malsena neonatorum, 290 
.Marasmus, .">().", 



[NDEX 



371 



Mask of pregnancy, 55 

Mastitis. 247 

Maternal impressions. 72 

Membranes, 110 

premature rupture, 225 
relation of rupture to labor, 
114 

rupture of, 109, 114 
Menstruation, definition of, 33 

during lactation, 157 

in infant, 298 

physiology of, -"'4 

relation to conception and 
pregnancy, 33 

systemic effects, 35 
Milk fever. 243 
Milk, elements of human, .">12 

excess of, 249 

fat-free, 317 

inflow, 156 

peptonizing, 338 

pasteurizing, 316 

quality, 251 

scarcity, 249 

sterilization, 316 

to dry up, 163 

whole milk, 317 
Milk leg, 262 
Mind in pregnancy, 72 
Moles, 86 
Monsters, 88, 308 
Mons veneris, 25 
Morning sickness, 58 
Multiple pregnancy, 83 

N 

Nausea, 58 
Nervous system, 56 
Neuralgia, 56 
Nipple, 30 
care of, 71 

cracks and fissures, 244 

imperfect, 245 

preparation for lactation, 

155 
rubber, 31S 
Normal labor, 107 

amount of blood lost. 119 
causes of. 107 
course of, 110 



Normal labor — Cont'd 
date of onset, 107 
duration of first stage, 114 
duration of second stage, 
114 

general effects, 118 

mechanism, 120 

subjective phenomena. 115 
Nurse, 98 

and cleanliness, 129, 323 

and history sheet, 131 

in obstetrics, 98 

in puerperal fever, 262 

outfit, 99 

qualifications, 323 

sterilizing, 101 
Nursery rules, 269 
Nursing periods, 156 
Nursing the child, 293 

O 

Odors of person, 324 
Oligohydramnios, 87 
Operations, preparations for, 
180 

why required, 179 
Ophthalmia neonatorum, 93, 

142, 192 
<)s, digital dilatation, 211 

physiologv of dilatation. Ill 

rigidity of, 222 
Ovaries, 23 
Ovulation, 33 
Ovum, 33 

death of, 96 

fertilization, 36 

implantation, 37 

mode of progress, 23 

relation to uterine cavity. 
52 

P 

Packs, wet. 213 
Pains, after, 154 
cause of, 109 

character of, 115. 131, 138 
false, 108 
from gas, 154 
regularity of, 110. 130 
Palpation, 134 



372 



INDEX 



Paralysis, facial. 201 
of shoulder (Erb's), 291 

Paraphimosis, 305 

Patient, care of, after deliv- 
ery, 144 
during second stage, 187 
examination of, 74, 1.*>. - ! 
in first stage, 1.'!.'! 
loss of weight post partum, 
155 

preparation of, 131, 138 
rest, 160 

visitors, 133, 1(31 
Pelvic floor rigidity, 223 
Pelvis, 17 

brim, 18 

contracted, 214 

diameters, 214 

false. 17 

measurements, -14 
quad ra tits of, 1 2 1 
shape, IN 
1 rue, 17 

upper strait. IN 
Pemphigus neonatorum, 296 
1 'erineorrha phy, 144 

instrument s. 139, 145, 14(i 

after care, 147 
Perineum, 2N, 25 

head on, 115 

preservation, 14.1 

repair, 143, 144 

torn in labor, ."50 
Peritoneum, 24 
Peritonitis, (see Infection) 
Phimosis, 305 
Phlebitis, 263 

Physical signs of pregnancv, 
59 

Pigmentation. 55, 77 
Pituitrin, 143, 224 
Placenta pnevia. 29 
Placenta, 41 

anomalies, 88 

early expression, 149 

infarcts, 88 

conditions for Crede expres- 
sion, 150 
manual removal, 150 
Pneumonia in child, 304 



Point of direction, 121 

Position, occipito-posterior, 178 

of breech, 165 

of face, 175 

of head, 121 

Walcher, 193 
Pregnancy, A.bderhalden 's test 
for, (il 

age of, 65 

albuminuria in, 77 

at fourth month, til 

bowels in, 68 

cathartics in. 68 

condylomata, 75 

constipation in. 75 

cramps, 86 

diabetes in, 95 

diagnosis, 57 

duration of, lift. 107 

extra uterine, 89 

fevers and, !M 

general effects. 56 

gingivitis, 75 

gonorrhoea, 93 

haemorrhages, 95 

haemorrhoids in, 86 

heart disease and, 94 

heartburn, 68 

herpes, 7<> 

hydramnios in, 87 

hygiene of, 60 

hyperemesie in. 7!» 

kidneys in, 68 

local effects, 51 

maternal changes, 51 

mental conditions in. 72 

pressure symptoms, 85 

probable signs, 6] 

pruritus, 70 

pyelitis, 79 

salivation, 75 

signs at 26th week, <'>2 

syphilis, 92 

toothache, 75 

toxaemias, 74 

1 uberculosis, 92 

varicose veins, 85 

vomiting in, 79 
Prematurity, 301 
Presentation, definition, 120 

frequency of vertex, 121 



!.\I)K.\ 



Presentation — Ooni M 

of breech, 105 

of face and brow , 17 1 

transverse, 174 
Pressure symptoms, 85 
Priapism, 308 
Proprietary foods, 314 
Pruritus in pregnancy, 7G 
Ptyalism, 75 
Puberty, 33 
Pubiotomy, 1&8 

after-care, 199 
Puerperal fever, 255 

disposiil of excreta, 201 

etiology, 255 

nurse and, 202 

prevention, 258 

symptoms, 2.19 

treatment, 260 
Puerperium, 151 

diet in, 1.12 

laxatives, 158 

standing orders for, 102 
Pulse in puerperium, 151 
Pyelitis, 79 
Pyloric stenosis, 303 

Q 

Quickening-, .19 
R 

ReCtal feeding, 333 
Rectal infusions, 212 
Rectum, 2.°, 

in labor, 23, 142 
Red gum, 297 
Penal disease, 95 
Rest, 160 

Room, setting up, 130, 180 
Rubber gloves, 136 
Rubber n ipples, •"• 1 s 

S 

Salivation, 75 
Second stage of labor, 1 14 
Sex. determination of. 65, 72 
Sexual relations. 7 1 
Sheet sling, 146, 18] 
Show, 109. 129 



Skin, changes, 5 I 

care of, 68 

eruptions, 55 

pigmentation, 55, 77 

striffi gravidarum, .14 
Snuffles,' :}04 
Solutions, 340 

percentage table of, ."141 
Souffle, funic, 65 

uterine, 03 
Spermatozoa, 36 
Spina bifida, 308 
Standing orders for nurse, t64 

for puerperium, 163 
Starvation fever, 270 
Sterile linen, application, 138, 
182 

Sterilization, 101, 323 

dressings, 325 

instruments, 327 

rubber goods, 328 
Stitches, care of, 100 

removal, 202 
Stomach capacity of child, 27.1 
Subinvolution, 155, 200, 261 
Subjective signs of pregnancy, 
57, 59 

Sudden death of infant. 309 

of mother, 263 
Sugar in urine, 09 
Sugars and Hours, .". 1 7 
Supplemental feedings, 310 
Supplies for house, 99 

for sterilization, 101 

preparation of, .'120 
Symphyseotomy, 198 
Syphilis and fretus, 88 

and pregnaney, 92 

of placenta, 88 

T 

Tampon of uterus, 202 

of vagina, 204 
Temperature in puerperium, 
151 

Third stage of labor, 117. 142. 
14.3 

conduct of, 149 
Thrombus, 263 
Thrush. 294 



374 



IX MX 



Thyroid gland, 56 
Toilet basket. 271 
Tongue-tie, 287 
Toothache, 75 
Toxaemia, 74 
Transfusion, 205 

in eclampsia, 240 
Tubercles of Montgomery, 31 
Tuberculosis and pregnancy, 
92 

Twilight sleep, 103 
Twins, 83 

U 

Umbilicus, 267 

Unavoidable haemorrhage, 228 

Urination, after delivery, 158 
of child, 273 

Urine, 56 

in pregnancy, 77 
in puerperium, 151 
sterile specimen, 200 
sterile specimen from child, 
200 

Urticaria, 294 

Utensils for milk modification, 
318 

Uterus, anatomy, 21 

changes in pregnancy, 51, 59 
currettage, 206 
displacements, 84 
height at various months of 

pregnancy, 64 
inertia, 223 



Uterus— Conl 'd 

malformations. 85 

rupture, 226 
Uterine souffle, 63 

V 

Vagina, anatomy. 2 1 

attachments, 21 

distensibility. 21 
Vaginal tampon, 20 I 

in abortion, 207 
Varicose veins, 85 
Ventral stalk, 40 
Version, 190, 192, 193 
Vestibule, 26 
Vessels of cord. 48 
Villi. 37 

Visitors, 133, 161 
Vomiting, 300, 321 

in pregnancy, 79 

in labor, 228 

uncontrollable, 79 
Vorhees bag. 224. 230 
Vulva, anatomy, 24 

care of, 143' 

preparation, 132 

W 

Walcher position, 173, 193 
Weaning, 252, 273 
Wet nurse, 25.'! 
Wharton 's jelly, 40 
Whey, 315 

Wiegand compression, 173, 191 
Witch's milk, 32 




SEP 6 1917